Octagam (IVIG)
Billing
Code: J1568
Description: Octagam injection
Unit: 0.5 g
Payment: $44.786
Pay quarter: Q4 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$2,687.16(ASP: $2,535.06, Margin: $152.10)
Code:
J1568# Units to bill:
60Prior Authorization
Prior auth criteria for Octagam may include but is not limited to:
1. Octagam is indicated for the treatment of primary humoral immunodeficiency (PI) in adult and pediatric patients two years of age and older.
2. The patient must have a diagnosis of PI or a combination of PI and hypogammaglobulinemia.
3. The patient must be intolerant of or have an inadequate response to replacement therapy with other immunoglobulin products.
4. The patient must have received prior authorization from the treating physician, including documentation of the patient’s medical history, lab results, and clinical response to other therapies.
5. The patient must have an individualized treatment plan that includes a dosing schedule and monitoring of immunoglobulin levels.
6. The patient must not have any contraindications to the use of Octagam.
Insurance prior auth guidelines:
Billable NDCs
68982-0840-01
Octagam (OCTAPHARMA)
1000 MG
68982-0840-02
Octagam (OCTAPHARMA)
2500 MG
68982-0840-03
Octagam (OCTAPHARMA)
5000 MG
68982-0840-04
Octagam (OCTAPHARMA)
10000 MG
68982-0850-01
Octagam (OCTAPHARMA)
2000 MG
68982-0850-02
Octagam (OCTAPHARMA)
5000 MG
68982-0850-03
Octagam (OCTAPHARMA)
10000 MG
68982-0850-04
Octagam (OCTAPHARMA)
20000 MG
68982-0850-05
Octagam (OCTAPHARMA)
30000 MG
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