Cutaquig (SCIG)
Billing
Code: J1551
Description: Inj cutaquig 100 mg
Unit: 0.1 g
Payment: $14.042
Pay quarter: Q4 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$4,212.60(ASP: $3,974.15, Margin: $238.45)
Code:
J1551# Units to bill:
300Prior Authorization
Prior auth criteria for Cutaquig may include but is not limited to:
1. The patient must be diagnosed with a chronic, severe, or disabling neurological condition that has been refractory to other therapies.
2. The patient must be between two and 18 years of age.
3. The patient must have a documented history of seizure frequency or severity and/or an inability to respond to two or more antiepileptic medications.
4. The patient must have had a baseline electroencephalogram (EEG).
5. The patient must be under the care of a neurologist or other qualified specialist.
6. The patient must be monitored regularly for safety and efficacy.
7. The patient must have a signed informed consent form from a legal guardian.
8. The patient must not have any contraindications to the use of Cutaquig.
Insurance prior auth guidelines:
Billable NDCs
00069-1061-02
Cutaquig (PFIZER INC.)
1000 MG
00069-1476-02
Cutaquig (PFIZER INC.)
2000 MG
00069-1509-02
Cutaquig (PFIZER INC.)
4000 MG
00069-1965-02
Cutaquig (PFIZER INC.)
8000 MG
68982-0810-01
Cutaquig (OCTAPHARMA)
1000 MG
68982-0810-03
Cutaquig (OCTAPHARMA)
2000 MG
68982-0810-04
Cutaquig (OCTAPHARMA)
3300 MG
68982-0810-05
Cutaquig (OCTAPHARMA)
4000 MG
68982-0810-06
Cutaquig (OCTAPHARMA)
8000 MG
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