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Cutaquig (SCIG)


Billing

Code: J1551

Description: Inj cutaquig 100 mg

Unit: 0.1 g

Payment: $14.042

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Calculate drug reimbursement


Total Reimbursement:

$4,212.60

(ASP: $3,974.15, Margin: $238.45)


Code:

J1551

# Units to bill:

300

Prior 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:

Aetna

United Healthcare

Anthem

Cigna


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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