Description: Octagam injection
Unit: 0.5 g
Pay quarter: Q4 2023
Dosage and Frequency
Calculate drug reimbursement
(ASP: $2,535.06, Margin: $152.10)
# Units to bill:60
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: