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Krystexxa (Pegloticase)


Code: J2507

Description: Pegloticase injection

Unit: 1 mg

Payment: $3307.045

Pay quarter: Q4 2023

Medicare history

Dosage and Frequency

Chronic gout

• 8mg IV every 2 weeks

Calculate drug reimbursement

Total Reimbursement:


(ASP: $24,958.83, Margin: $1,497.53)



# Units to bill:


Prior Authorization

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

1. Patient must have been diagnosed with chronic gout for at least 1 year and have failed to respond to an adequate trial of conventional therapy.

2. Patient must have two or more episodes of gouty arthritis in the past 12 months.

3. Patient must have had at least three episodes of gouty arthritis in the past 24 months.

4. Patient must have serum uric acid >6 mg/dL on two occasions within a four-week period.

5. Patient must have renal function (measured by estimated creatinine clearance) above 30 mL/min.

6. Patient must not have any known hypersensitivity to the active ingredient or to any excipients in the product.

7. Patient must have a negative pregnancy test prior to initiation of therapy.

8. Patient must not have any clinically active hepatic, renal, or cardiac disease.

9. Patient must not have any other serious medical condition that may increase their risk of adverse reactions.

10. Patient must not have had any recent or current malignancy.

Insurance prior auth guidelines:


United Healthcare



Billable NDCs


Krystexxa (HORIZON)

8 MG


Drug Enrollment Form