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Hizentra (SCIG)


Billing

Code: J1559

Description: Hizentra injection

Unit: 0.1 g

Payment: $12.728

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Calculate drug reimbursement


Total Reimbursement:

$3,818.40

(ASP: $3,602.26, Margin: $216.14)


Code:

J1559

# Units to bill:

300

Prior Authorization

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


1. The patient must have an underlying diagnosis of primary immunodeficiency (PIDD).

2. The patient must have an immunoglobulin G (IgG) level of less than 400 mg/dL.

3. The patient must have a history of recurrent infections or symptoms that are likely to be due to PIDD.

4. The patient must have failed treatment with a first-line immunoglobulin replacement therapy.

5. The patient must have documentation of an allergic reaction or intolerance to a first-line immunoglobulin replacement therapy.

6. The patient must meet the criteria for treatment as outlined in the prescribing information for Hizentra.


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

44206-0451-01

Hizentra (CSL BEHRING LLC)

1000 MG


44206-0452-02

Hizentra (CSL BEHRING LLC)

2000 MG


44206-0454-04

Hizentra (CSL BEHRING LLC)

4000 MG


44206-0455-10

Hizentra (CSL BEHRING LLC)

10000 MG


44206-0456-21

Hizentra (CSL BEHRING LLC)

1000 MG


44206-0457-22

Hizentra (CSL BEHRING LLC)

2000 MG


44206-0458-24

Hizentra (CSL BEHRING LLC)

4000 MG



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