Drug IndexOctagam (Immune Globulin Intravenous (Human) 5%)
Billing
Code: J1568
Description: Octagam injection
Unit: 500 MG
Payment: $47.740
Pay quarter: Q3 2024
Covered in Part D: Yes
Avg tier level: 4
Drug Cost
Calculate drug cost and reimbursement
Total WAC:
N/ATotal Reimbursement:
N/A(ASP: N/A, Margin: N/A)
.
.# Units to bill:
N/ABillable NDCs
00069-6002-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-6002-02) / 20 mL in 1 BOTTLE, GLASS (0069-6002-01)
00069-6111-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-6111-02) / 100 mL in 1 BOTTLE, GLASS (0069-6111-01)
00069-6237-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-6237-02) / 200 mL in 1 BOTTLE, GLASS (0069-6237-01)
00069-6339-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-6339-02) / 300 mL in 1 BOTTLE, GLASS (0069-6339-01)
00069-6550-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-6550-02) / 50 mL in 1 BOTTLE, GLASS (0069-6550-01)
00069-8400-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-8400-02) / 20 mL in 1 BOTTLE, GLASS (0069-8400-01)
00069-8425-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-8425-02) / 50 mL in 1 BOTTLE, GLASS (0069-8425-01)
00069-8451-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-8451-02) / 100 mL in 1 BOTTLE, GLASS (0069-8451-01)
00069-8476-02
OCTAGAM (Pfizer Laboratories Div Pfizer Inc)
1 BOTTLE, GLASS in 1 CARTON (0069-8476-02) / 200 mL in 1 BOTTLE, GLASS (0069-8476-01)
68982-0840-01
OCTAGAM (Octapharma USA Inc)
20 mL in 1 BOTTLE, GLASS (68982-840-01)
68982-0840-02
OCTAGAM (Octapharma USA Inc)
50 mL in 1 BOTTLE, GLASS (68982-840-02)
68982-0840-03
OCTAGAM (Octapharma USA Inc)
100 mL in 1 BOTTLE, GLASS (68982-840-03)
68982-0840-04
OCTAGAM (Octapharma USA Inc)
200 mL in 1 BOTTLE, GLASS (68982-840-04)
68982-0840-05
OCTAGAM (Octapharma USA Inc)
500 mL in 1 BOTTLE, GLASS (68982-840-05)
68982-0850-01
OCTAGAM (Octapharma USA Inc)
20 mL in 1 BOTTLE, GLASS (68982-850-01)
68982-0850-02
OCTAGAM (Octapharma USA Inc)
50 mL in 1 BOTTLE, GLASS (68982-850-02)
68982-0850-03
OCTAGAM (Octapharma USA Inc)
100 mL in 1 BOTTLE, GLASS (68982-850-03)
68982-0850-04
OCTAGAM (Octapharma USA Inc)
200 mL in 1 BOTTLE, GLASS (68982-850-04)
68982-0850-05
OCTAGAM (Octapharma USA Inc)
300 mL in 1 BOTTLE, GLASS (68982-850-05)
Prior Authorization
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