Hizentra (SCIG)
Billing
Code: J1559
Description: Hizentra injection
Unit: 0.1 g
Payment: $12.728
Pay quarter: Q4 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$3,818.40(ASP: $3,602.26, Margin: $216.14)
Code:
J1559# Units to bill:
300Prior 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:
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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