Description: Inj, aducanumab-avwa, 2 mg
Unit: 2 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 1mg/kg IV for infusion 1 and 2
• 3mg/kg IV for infusion 3 and 4
• 6mg/kg IV for infusion 5 and 6
• 10mg/kg IV for infusion 7+
• Administer every 4 weeks
Calculate drug reimbursement
(ASP: $2,255.85, Margin: $135.35)
# Units to bill:400
Prior auth criteria for Aduhelm may include but is not limited to:
1. The patient must be diagnosed with Alzheimer’s disease by a physician or other qualified healthcare professional.
2. The patient must have a Mini-Mental State Examination (MMSE) score of at least 24, with a documented decline from a prior MMSE score.
3. The patient must be between the ages of 50 and 85.
4. The patient must be ambulatory and able to tolerate the infusion procedure.
5. The patient must have an ApoE genotype of either ?3/3, ?3/4, or ?4/4.
6. The patient must not have any active malignancy or immunosuppressive disease.
7. The patient must not have any evidence of severe hepatic impairment.
8. The patient must not have any known hypersensitivity to antibodies or other drugs.
9. The patient must not have any active infections requiring antibiotics.
10. The patient must not have any active clinically significant cardiac or pulmonary disorders.
Insurance prior auth guidelines: