Effective with date of service Oct. 3, 2022, the Medicaid and NC Health Choice programs cover Ranibizumab-eqrn injection, for intravitreal use (Cimerli) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J3590 - Unclassified biologics.
Strength/Package Size(s): Single-dose glass vial designed to provide 0.05 mL for intravitreal injections:
- 10 mg/mL solution (Cimerli 0.5 mg)
- 6 mg/mL solution (Cimerli 0.3 mg)
Indications and Recommended Dose (see full prescribing information for further detail):
Neovascular (Wet) Age-Related Macular Degeneration (AMD):
- Cimerli 0.5 mg (0.05 mL) is recommended to be administered by intravitreal injection once a month (approximately 28 days)
- Although not as effective, patients may be treated with 3 monthly doses followed by less frequent dosing with regular assessment
- Although not as effective, patients may also be treated with one dose every 3 months after 4 monthly doses. Patients should be assessed regularly.
Macular Edema Following Retinal Vein Occlusion (RVO): Cimerli 0.5 mg (0.05 mL) is recommended to be administered by intravitreal injection once a month (approximately 28 days).
Diabetic Macular Edema (DME) and Diabetic Retinopathy (DR): Cimerli 0.3 mg (0.05 mL) is recommended to be administered by intravitreal injection once a month (approximately 28 days).
Myopic Choroidal Neovascularization (mCNV): Cimerli 0.5 mg (0.05 mL) is recommended to be initially administered by intravitreal injection once a month (approximately 28 days) for up to 3 months. Patients may be retreated if needed.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
Neovascular (Wet) Age-Related Macular Degeneration (AMD):
H35.3211 - Exudative AMD, right eye, with active choroidal neovascularization;
H35.3212 - Exudative AMD, right eye, with inactive choroidal neovascularization;
H35.3213 - Exudative AMD, right eye, with inactive scar;
H35.3221 - Exudative AMD, left eye, with active choroidal neovascularization;
H35.3222 - Exudative AMD, left eye, with inactive choroidal neovascularization;
H35.3223 - Exudative AMD, left eye, with inactive scar;
H35.3231 - Exudative AMD, bilateral, with active choroidal neovascularization;
H35.3232 - Exudative AMD, bilateral, with inactive choroidal neovascularization;
H35.3233 - Exudative AMD, bilateral, with inactive scar;
Macular Edema Following Retinal Vein Occlusion (RVO):
H34.8110 - Central retinal vein occlusion, right eye, with macular edema;
H34.8120 - Central retinal vein occlusion, left eye, with macular edema;
H34.8130 - Central retinal vein occlusion, bilateral, with macular edema;
H34.8310 - Tributary (branch) retinal vein occlusion, right eye, with macular edema;
H34.8320 - Tributary (branch) retinal vein occlusion, left eye, with macular edema;
H34.8330 - Tributary (branch) retinal vein occlusion, bilateral, with macular edema;
Diabetic Macular Edema (DME):
E08.3111 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified with macular edema, right eye;
E08.3112 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified with macular edema, left eye;
E08.3113 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified with macular edema, bilateral;
E08.3211 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E08.3212 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E08.3213 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E08.3311 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E08.3312 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E08.3313 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E08.3411 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E08.3412 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E08.3413 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye;
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye;
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral;
E08.37X1 Diabetes mellitus due to underlying condition diabetic retinopathy with macular edema resolved following treatment, right eye;
E08.37X2 Diabetes mellitus due to underlying condition diabetic retinopathy with macular edema resolved following treatment, left eye;
E08.37X3 Diabetes mellitus due to underlying condition diabetic retinopathy with macular edema resolved following treatment, bilateral;
E09.3111 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified with macular edema, right eye;
E09.3112 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified with macular edema, left eye;
E09.3113 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified with macular edema, bilateral;
E09.3211 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E09.3212 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E09.3213 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E09.3311 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E09.3312 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E09.3313 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E09.3411 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E09.3412 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E09.3413 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E09.37X1 Drug-induced diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E09.37X2 Drug-induced diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E09.37X3 Drug-induced diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
E10.3111 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, right eye;
E10.3112 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, left eye;
E10.3113 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, bilateral;
E10.3211 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E10.3212 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E10.3213 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E10.3311 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E10.3312 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E10.3313 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E10.3411 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E10.3412 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E10.3413 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E10.37X1 Type 1 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E10.37X2 Type 1 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E10.37X3 Type 1 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
E11.3111 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, right eye;
E11.3112 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, left eye;
E11.3113 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, bilateral;
E11.3211 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E11.3212 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E11.3213 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E11.3311 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E11.3312 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E11.3313 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E11.3411 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E11.3412 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E11.3413 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E11.37X1 Type 2 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E11.37X2 Type 2 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E11.37X3 Type 2 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
E13.3111 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema, right eye;
E13.3112 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema, left eye;
E13.3113 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema, bilateral;
E13.3211 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E13.3212 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E13.3213 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E13.3311 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E13.3312 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E13.3313 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E13.3411 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E13.3412 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E13.3413 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E13.37X1 Other specified diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E13.37X2 Other specified diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E13.37X3 Other specified diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
Diabetic Retinopathy (DR):
E08.3111 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified with macular edema, right eye;
E08.3112 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified with macular edema, left eye;
E08.3113 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified with macular edema, bilateral;
E08.3191 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified without macular edema, right eye;
E08.3192 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified without macular edema, left eye;
E08.3193 Diabetes mellitus due to underlying condition diabetic retinopathy not otherwise specified without macular edema, bilateral;
E08.3211 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E08.3212 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E08.3213 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E08.3291 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy without macular edema, right eye;
E08.3292 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy without macular edema, left eye;
E08.3293 Diabetes mellitus due to underlying condition with mild non-proliferative diabetic retinopathy without macular edema, bilateral;
E08.3311 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E08.3312 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E08.3313 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E08.3391 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy without macular edema, right eye;
E08.3392 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy without macular edema, left eye;
E08.3393 Diabetes mellitus due to underlying condition with moderate non-proliferative diabetic retinopathy without macular edema, bilateral;
E08.3411 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E08.3412 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E08.3413 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E08.3491 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy without macular edema, right eye;
E08.3492 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy without macular edema, left eye;
E08.3493 Diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy without macular edema, bilateral;
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye;
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye;
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral;
E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye;
E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye;
E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral;
E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye;
E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye;
E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral;
E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye;
E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye;
E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral;
E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye;
E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye;
E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral;
E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye;
E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye;
E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral;
E08.37X1 Diabetes mellitus due to underlying condition diabetic retinopathy with macular edema resolved following treatment, right eye;
E08.37X2 Diabetes mellitus due to underlying condition diabetic retinopathy with macular edema resolved following treatment, left eye;
E08.37X3 Diabetes mellitus due to underlying condition diabetic retinopathy with macular edema resolved following treatment, bilateral;
E09.3111 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified with macular edema, right eye;
E09.3112 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified with macular edema, left eye;
E09.3113 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified with macular edema, bilateral;
E09.3191 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified without macular edema, right eye;
E09.3192 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified without macular edema, left eye;
E09.3193 Drug-induced diabetes mellitus diabetic retinopathy not otherwise specified without macular edema, bilateral;
E09.3211 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E09.3212 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E09.3213 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E09.3291 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, right eye;
E09.3292 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, left eye;
E09.3293 Drug or chemical induced diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, bilateral;
E09.3311 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E09.3312 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E09.3313 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E09.3391 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, right eye;
E09.3392 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, left eye;
E09.3393 Drug or chemical induced diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, bilateral;
E09.3411 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E09.3412 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E09.3413 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E09.3491 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, right eye;
E09.3492 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, left eye;
E09.3493 Drug or chemical induced diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, bilateral;
E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye;
E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye;
E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral;
E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye;
E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye;
E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral;
E09.3541 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye;
E09.3542 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye;
E09.3543 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral;
E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye;
E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye;
E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral;
E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye;
E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye;
E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral;
E09.37X1 Drug-induced diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E09.37X2 Drug-induced diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E09.37X3 Drug-induced diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
E10.3111 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, right eye;
E10.3112 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, left eye;
E10.3113 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, bilateral;
E10.3191 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified without macular edema, right eye;
E10.3192 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified without macular edema, left eye;
E10.3193 Type 1 diabetes mellitus with diabetic retinopathy not otherwise specified without macular edema, bilateral;
E10.3211 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E10.3212 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E10.3213 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E10.3291 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, right eye;
E10.3292 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, left eye;
E10.3293 Type 1 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, bilateral;
E10.3311 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E10.3312 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E10.3313 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E10.3391 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, right eye;
E10.3392 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, left eye;
E10.3393 Type 1 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, bilateral;
E10.3411 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E10.3412 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E10.3413 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E10.3491 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, right eye;
E10.3492 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, left eye;
E10.3493 Type 1 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, bilateral;
E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye;
E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye;
E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral;
E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye;
E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye;
E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral;
E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye;
E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye;
E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral;
E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye;
E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye;
E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral;
E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye;
E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye;
E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral;
E10.37X1 Type 1 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E10.37X2 Type 1 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E10.37X3 Type 1 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
E11.3111 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, right eye;
E11.3112 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, left eye;
E11.3113 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified with macular edema, bilateral;
E11.3191 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified without macular edema, right eye;
E11.3192 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified without macular edema, left eye;
E11.3193 Type 2 diabetes mellitus with diabetic retinopathy not otherwise specified without macular edema, bilateral;
E11.3211 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E11.3212 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E11.3213 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E11.3291 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, right eye;
E11.3292 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, left eye;
E11.3293 Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, bilateral;
E11.3311 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E11.3312 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E11.3313 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E11.3391 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, right eye;
E11.3392 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, left eye;
E11.3393 Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, bilateral;
E11.3411 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E11.3412 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E11.3413 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E11.3491 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, right eye;
E11.3492 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, left eye;
E11.3493 Type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, bilateral;
E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye;
E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye;
E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral;
E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye;
E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye;
E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral;
E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye;
E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye;
E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral;
E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye;
E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye;
E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral;
E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye;
E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye;
E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral;
E11.37X1 Type 2 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E11.37X2 Type 2 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E11.37X3 Type 2 diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
E13.3111 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema, right eye;
E13.3112 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema, left eye;
E13.3113 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema, bilateral;
E13.3191 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema, right eye;
E13.3192 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema, left eye;
E13.3193 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema, bilateral;
E13.3211 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, right eye;
E13.3212 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, left eye;
E13.3213 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy with macular edema, bilateral;
E13.3291 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, right eye;
E13.3292 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, left eye;
E13.3293 Other specified diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, bilateral;
E13.3311 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, right eye;
E13.3312 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, left eye;
E13.3313 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral;
E13.3391 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, right eye;
E13.3392 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, left eye;
E13.3393 Other specified diabetes mellitus with moderate non-proliferative diabetic retinopathy without macular edema, bilateral;
E13.3411 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, right eye;
E13.3412 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, left eye;
E13.3413 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral;
E13.3491 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, right eye;
E13.3492 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, left eye;
E13.3493 Other specified diabetes mellitus with severe non-proliferative diabetic retinopathy without macular edema, bilateral;
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye;
E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye;
E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral;
E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye;
E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye;
E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral;
E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye;
E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye;
E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral;
E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye;
E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye;
E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral;
E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye;
E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye;
E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral;
E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye;
E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye;
E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral;
E13.37X1 Other specified diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, right eye;
E13.37X2 Other specified diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, left eye;
E13.37X3 Other specified diabetes mellitus diabetic retinopathy with macular edema resolved following treatment, bilateral;
Myopic Choroidal Neovascularization (mCNV):
H35.051 - Myopic choroidal neovascularization retinal neovascularization, right eye;
H35.052 - Myopic choroidal neovascularization retinal neovascularization, left eye;
H35.053 - Myopic choroidal neovascularization retinal neovascularization, bilateral;
H44.21 - Myopic choroidal neovascularization degenerative myopia, right eye;
H44.22 - Myopic choroidal neovascularization degenerative myopia, left eye;
H44.23 - Myopic choroidal neovascularization degenerative myopia, bilateral;
H44.2A1 - mCNV degenerative myopia with choroidal neovascularization, right eye;
H44.2A2 - mCNV degenerative myopia with choroidal neovascularization, left eye;
H44.2A3 - mCNV degenerative myopia with choroidal neovascularization, bilateral
- Providers must bill with HCPCS code: J3590 - Unclassified biologics
- One Medicaid and NC Health Choice unit of coverage is: 0.1 mg
- The maximum reimbursement rate per unit is: $293.76
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 70114-0440-01, 70114-0441-01
- 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 Medicaid's PADP web page.
Contact
NCTracks Call Center: 800-688-6696