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Lioresal (Baclofen)


Billing

Code: J0476

Description: Baclofen intrathecal trial

Unit: 50 mcg

Payment: $46.921

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Calculate drug reimbursement


Total Reimbursement:

$46.92

(ASP: $44.27, Margin: $2.66)


Code:

J0476

# Units to bill:

1

Prior Authorization

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





Insurance prior auth guidelines:


Billable NDCs

25021-0681-71

BACLOFEN (SAGENT PHARMACEUTICALS INC)

100 MCG


66794-0151-01

GABLOFEN (PIRAMAL CRITICAL CARE)

50 MCG


70121-2496-05

LIORESAL (AMNEAL PHARMACEUTICALS INC)

250 MCG


70257-0562-55

Lioresal (SAOL THERAPEUTICS)

250 MCG



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