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Gammagard liquid (IVIG)


Billing

Code: J1569

Description: Gammagard liquid injection

Unit: 0.5 g

Payment: $44.460

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Calculate drug reimbursement


Total Reimbursement:

$2,667.60

(ASP: $2,516.60, Margin: $151.00)


Code:

J1569

# Units to bill:

60

Prior Authorization

Prior auth criteria for Gammagard liquid may include but is not limited to:


1. The patient must be over the age of two.
2. The patient must have a diagnosis of primary immunodeficiency, as defined by the World Health Organization (WHO).
3. The patient must not have any contraindications to intravenous immunoglobulin therapy.
4. The patient must have had an inadequate response to other therapies, such as antibiotics, antifungal medications, or other immunomodulatory agents.
5. The patient must have had an inadequate response to oral immunoglobulin therapy.
6. The patient must have laboratory evidence of hypogammaglobulinemia.
7. The patient must have an increased risk of recurrent infections.
8. The patient must not have any known allergy to Gammagard Liquid or any of its components.


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

00944-2700-02

GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)

1000 MG


00944-2700-03

GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)

2500 MG


00944-2700-04

GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)

5000 MG


00944-2700-05

GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)

10000 MG


00944-2700-06

GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)

20000 MG


00944-2700-07

GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)

30000 MG



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