Effective with date of service Jan. 20, 2023, the Medicaid and NC Health Choice programs cover fecal microbiota, live - jslm suspension, for rectal use (Rebyota) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size: Suspension. A single dose is 150 mL.
Indicated for the prevention of recurrence of Clostridioides difficile infection (CDI) in individuals 18 years of age and older, following antibiotic treatment for recurrent CDI.
Limitation of Use: Rebyota is not indicated for treatment of CDI.
Recommended Dose: Administer a single dose of 150 mL rectally of Rebyota. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
A04.71 - Enterocolitis due to Clostridium difficile, recurrent;
A04.72 - Enterocolitis due to Clostridium difficile, not specified as recurrent
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and NC Health Choice unit of coverage is: 1 mL
- The maximum reimbursement rate per unit is: $64.80000
- Providers must bilThe NDC units should be reported as "UN1."
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update
- For additional information regarding NDC claim requirements related to the PADP, refer to the PADP Clinical Coverage Policy 1B, Attachment A, H.7 on DHB's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP reimburses for drugs billed for Medicaid and NC Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the "UD" modifier on the drug detail.
- The fee schedule for the PADP is available on the NC Medicaid’s Fee Schedule & Covered Code portal.
NCTracks Call Center: 800-688-6696