Effective with date of service Jan. 27, 2023, the Medicaid and NC Health Choice programs cover ublituximab-xiiy injection, for intravenous use (Briumvi) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size: Injection: 150 mg/6 mL (25 mg/mL) in a single-dose vial
Indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.
Recommended Dose: First infusion 150mg intravenous. Second infusion 450mg intravenous two weeks after the first infusion. Subsequent infusions 450mg intravenous infusion 24 weeks after first infusion and every 24 weeks thereafter. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code required for billing is: G35 - Multiple sclerosis
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $70.80000
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 73150-0150-06
- The NDC units should be reported as "UN1."
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and PADP Clinical Coverage Policy 1B, Attachment A, H.7 on Medicaid’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 Fee Schedule & Covered Code portal.
Contact
NCTracks Call Center: 800-688-6696