Effective with date of service Sept. 6, 2023, NC Medicaid Direct and NC Medicaid Managed Care cover avacincaptad pegol intravitreal solution (Izervay) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3490 - Unclassified drugs.
Strength/Package Size: Intravitreal solution: 20 mg/mL in a single-dose vial
Avacincaptad pegol intravitreal solution is indicated for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD).
Recommended Dose: The recommended dose for Izervay is 2 mg (0.1 mL of 20 mg/mL solution) administered by intravitreal injection to each affected eye once monthly (approximately 28 ± 7 days) for up to 12 months.
See full prescribing information for further detail.
For Medicaid Billing
- The ICD-10-CM diagnosis codes required for billing are:
- H35.3113 - Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement;
- H35.3114 - Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement;
- H35.3123 - Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement;
- H35.3124 - Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement;
- H35.3133 - Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement;
- H35.3134 - Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement
- Providers must bill with HCPCS code: J3490 - Unclassified drugs
- One Medicaid unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $1,134.00000
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 82829-0002-01
- The 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 NC Medicaid's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP reimburses for drugs billed for Medicaid 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 their actual 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.
ICD-10-CM Manual. American Medical Association, 2023 manual.
*Information current as of Sept. 29, 2023, and is not a substitute for professional judgment. For full prescribing information, please refer to current package insert or other appropriate sources prior to making clinical judgments.
Contact
NCTracks Call Center: 800-688-6696
*Information current as of Sept. 19, 2023, and is not a substitute for professional judgment. For full prescribing information, please refer to current package insert or other appropriate sources prior to making clinical judgments.