Drug IndexLioresal (Baclofen)


Billing

Code: J0476

Description: Baclofen intrathecal trial

Unit: 50 MCG

Payment: $43.552

Pay quarter: Q4 2024

Covered in Part D: No

Drug Cost

Calculate drug cost and reimbursement


Total WAC:

N/A

Total Reimbursement:

N/A

(ASP: N/A, Margin: N/A)

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# Units to bill:

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Billable NDCs

70121-2496-05

Lioresal (Amneal Pharmaceuticals LLC)

5 AMPULE in 1 BOX (70121-2496-5) / 1 mL in 1 AMPULE


70121-2501-01

Lioresal (Amneal Pharmaceuticals LLC)

1 AMPULE in 1 BOX (70121-2501-1) / 1 KIT in 1 AMPULE


70121-2502-02

Lioresal (Amneal Pharmaceuticals LLC)

2 AMPULE in 1 BOX (70121-2502-2) / 1 KIT in 1 AMPULE


70121-2503-01

Lioresal (Amneal Pharmaceuticals LLC)

1 AMPULE in 1 BOX (70121-2503-1) / 1 KIT in 1 AMPULE


70121-2504-02

Lioresal (Amneal Pharmaceuticals LLC)

2 AMPULE in 1 BOX (70121-2504-2) / 1 KIT in 1 AMPULE


70121-2505-02

Lioresal (Amneal Pharmaceuticals LLC)

2 AMPULE in 1 BOX (70121-2505-2) / 1 KIT in 1 AMPULE


70257-0560-01

Lioresal (Saol Therapeutics Inc.)

1 AMPULE in 1 BOX (70257-560-01) / 20 mL in 1 AMPULE (70257-560-20)


70257-0560-02

Lioresal (Saol Therapeutics Inc.)

2 AMPULE in 1 BOX (70257-560-02) / 20 mL in 1 AMPULE (70257-560-20)


70257-0561-02

Lioresal (Saol Therapeutics Inc.)

2 AMPULE in 1 BOX (70257-561-02) / 5 mL in 1 AMPULE (70257-561-05)


70257-0562-55

Lioresal (Saol Therapeutics Inc.)

5 AMPULE in 1 BOX (70257-562-55) / 1 mL in 1 AMPULE (70257-562-11)


70257-0563-01

Lioresal (Saol Therapeutics Inc.)

1 AMPULE in 1 BOX (70257-563-01) / 20 mL in 1 AMPULE (70257-563-20)


70257-0563-02

Lioresal (Saol Therapeutics Inc.)

2 AMPULE in 1 BOX (70257-563-02) / 20 mL in 1 AMPULE (70257-563-20)


Prior Authorization

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