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Panzyga (IVIG)


Billing

Code: J1576

Description: Inj, panzyga, 500 mg

Unit: 0.5 g

Payment: $65.704

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Calculate drug reimbursement


Total Reimbursement:

$3,942.24

(ASP: $3,719.09, Margin: $223.15)


Code:

J1576

# Units to bill:

60

Prior Authorization

Prior auth criteria for Panzyga may include but is not limited to:


1. The patient must have a diagnosis of primary immunodeficiency (PID)
2. The patient must meet the criteria for one of the following conditions:
* Common variable immunodeficiency
* X-linked agammaglobulinemia
* Severe combined immunodeficiency
* Wiskott-Aldrich syndrome
* Chronic granulomatous disease
* Hyper IgM syndrome
3. The patient must have failed to respond to or is intolerant to conventional therapy
4. The requested dose must be appropriate for the patient's weight
5. The patient must have a signed consent form indicating their understanding of the risks and benefits of treatment
6. The patient must have a negative pregnancy test if they are of childbearing potential
7. The patient must have a serum IgG level ?400 mg/dL
8. The patient must have evidence of an active infection or an increased risk of infection


Insurance prior auth guidelines:

Aetna

United Healthcare

Anthem

Cigna


Billable NDCs

00069-1109-02

PANZYGA (PFIZER INC.)

2500 MG


00069-1224-02

PANZYGA (PFIZER INC.)

5000 MG


00069-1312-02

PANZYGA (PFIZER INC.)

10000 MG


00069-1415-02

PANZYGA (PFIZER INC.)

20000 MG


00069-1558-02

PANZYGA (PFIZER INC.)

30000 MG


68982-0820-02

PANZYGA (PFIZER INC.)

2500 MG


68982-0820-04

PANZYGA (PFIZER INC.)

10000 MG


68982-0820-05

PANZYGA (PFIZER INC.)

20000 MG


68982-0820-06

PANZYGA (PFIZER INC.)

30000 MG


68982-0822-02

PANZYGA (OCTAPHARMA)

2500 MG


68982-0822-03

PANZYGA (OCTAPHARMA)

5000 MG


68982-0822-04

PANZYGA (OCTAPHARMA)

10000 MG


68982-0822-05

PANZYGA (OCTAPHARMA)

20000 MG


68982-0822-06

PANZYGA (OCTAPHARMA)

30000 MG



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