Gammaplex (IVIG)
Billing
Code: J1557
Description: Gammaplex injection
Unit: 0.5 g
Payment: $57.010
Pay quarter: Q4 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$3,420.60(ASP: $3,226.98, Margin: $193.62)
Code:
J1557# Units to bill:
60Prior Authorization
Prior auth criteria for Gammaplex may include but is not limited to:
1. The patient must have an established diagnosis of primary immunodeficiency (PID) or chronic lymphocytic leukemia (CLL).
2. The patient must have failed to respond to standard therapies.
3. The patient must have laboratory evidence of a low immunoglobulin level.
4. The patient must have a documented history of frequent infections.
5. The patient must have a documented history of recurrent infections.
6. The patient must have a documented history of infections that were unresponsive to antibiotic therapy.
7. The patient must have a documented history of at least one serious infection in the past year.
8. The patient must not have any contraindications or other conditions that would make Gammaplex therapy unsafe or ineffective.
9. The patient must agree to comply with all instructions regarding Gammaplex use and monitoring.
Insurance prior auth guidelines:
Billable NDCs
64208-8234-02
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
5000 MG
64208-8234-03
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
10000 MG
64208-8234-04
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
20000 MG
64208-8234-06
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
5000 MG
64208-8234-07
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
10000 MG
64208-8234-08
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
20000 MG
64208-8235-01
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
5000 MG
64208-8235-02
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
10000 MG
64208-8235-03
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
20000 MG
64208-8235-05
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
5000 MG
64208-8235-06
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
10000 MG
64208-8235-07
GAMMAPLEX (BIO PRODUCTS LABORATORY, LTD)
20000 MG
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