Description: Inj. lumasiran, 0.5 mg
Unit: 0.5 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 6mg/kg SQ every 1 month for 3 doses if patient weighs less than 20kg
• 3mg/kg SQ every 1 month for 3 doses if patient weighs 20kg or above
• 3mg/kg SQ every 1 month if patient weighs less than 10kg
• 6mg/kg SQ every 3 months if patient weighs 10kg to less than 20kg
• 3mg/kg SQ every 3 months if patient weighs 20kg or above
Calculate drug reimbursement
(ASP: $144,677.43, Margin: $8,680.65)
# Units to bill:480
Prior auth criteria for Oxlumo may include but is not limited to:
1. Oxlumo should be prescribed for patients 18 years of age and older who have been diagnosed with primary hyperoxaluria type 1 (PH1) by a healthcare professional.
2. The patient must have documented evidence of either a positive urinary oxalate/creatinine ratio greater than 0.8 mg/mg or oxalate stone formation.
3. The patient must not have had a prior allergic reaction to Oxlumo or any of its components.
4. The patient must have a body mass index (BMI) of 18.5 or greater.
5. The patient must not have any other medical conditions that would contraindicate the use of Oxlumo.
6. The patient must not be pregnant or breastfeeding.
7. The patient must have a serum creatinine level of less than 2.5 mg/dL.
Insurance prior auth guidelines:
Oxlumo (ALNYLAM PHARMACEUTICALS, INC.)