KMAP BULLETIN: <mark>Update</mark> - High Dollar Rare Disease Drug List Update <mark>Q3 2023</mark>
Date: 12/04/23
KMAP GENERAL BULLETIN 23264 (PDF)
The following drugs are covered on the Managed Care Organization (MCO) High Dollar Rare Disease Drug List. The reimbursement for some high dollar rare disease drugs will be based on actual acquisition cost plus a handling fee.
Procedure code 99199 and modifier U1 will be utilized for reimbursement for the handling fee of drugs that are a one-time treatment and reimbursed a one-time amount of $250.00. Procedure code 99199 and modifier U3 will be used to bill for reimbursement of the handling fee for all other drugs listed in the table below and reimbursed at $50.00 for each administration of the drug. Prior authorization (PA) will still be required, along with the purchasing invoice for the drug billed. There will be no additional payment for these services.
High dollar rare disease drugs are to be billed as outpatient by the facility and will not be content of service. An exception to the inpatient/outpatient claims edits for same day billing will be allowed for these drugs. Payment for these drugs should be allowed outside of inpatient hospital reimbursement.
Drugs added to the High Dollar Rare Disease Drug List effective July 1, 2022:
| Drug/Biologic | Handling Fee |
|---|---|
| Amondys 45 (casimersen) | $50 |
| Exondys 51 (eteplirsen) | $50 |
| Givlaari® (givosiran) | $50 |
| Soliris® (eculizumab) | $50 |
| Viltepso (viltolarsen) | $50 |
| Vyondys 53 (golodirsen) | $50 |
| Abecma® (idecabtagene vicleucel) | $250 |
| Breyanzi® (lisocabtagene maraleucel) | $250 |
| Carvykti (ciltacabtagene autoleucel) | $250 |
| Kymriah® (tisagenlecleucel) | $250 |
| Luxturna® (voretigene neparvovec) | $250 |
| Spinraza® (nusinersen) | $250 |
| Tecartus® (brexucabtagene autoleucel | $250 |
| Yescarta® (axicabtagene ciloleucel) | $250 |
| Zolgensma® (onasemnogene abeparvovec-xioi) | $250 |
Drugs added to the High Dollar Rare Disease Drug List effective January 1, 2023:
| Drug/Biologic | Handling Fee |
|---|---|
| Amvuttra (vutrisiran) | $50 |
| Enjaymo® (sutimlimab-jome) | $50 |
| Onpattro® (patisiran) | $50 |
| Ryplazim® (plasminogen- human-tvmh,) | $50 |
| Tegsedi® (inotersen) | $50 |
| Tepezza (teprotumumab) | $50 |
| Ultomiris® (ravulizumab) | $50 |
| Voxzogo® (vosoritide) | $50 |
| Xenpozyme® (olipudase alfa) | $50 |
| Hemgenix® (etranacogene dezaparvovec) | $250 |
| Zynteglo® (betibeglogene autotemcel)* | $250 |
Drugs added to the High Dollar Rare Disease Drug List effective July 1, 2023:
| Drug/Biologic | Handling Fee |
|---|---|
| Brineura® (cerliponase alfa) | $50 |
| Lamzede® (velmanase alfa-tycv) | $50 |
| Oxlumo® (lumasiran) | $50 |
| Vyjuvek (beremagene geperpavec-svdt) | $50 |
| Elevidys (delandistrogene moxeparvovec-rokl) | $250 |
| Omisirge (omidubicel) | $250 |
| Roctavian (valoctocogene roxaparvovec-rvox) | $250 |
Note: The effective date of the policy is July 1, 2023. The implementation of State policy by the KanCare MCOs may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.