Prolastin-C - CuraFi

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Prolastin-C (A1-PI)

Billing

Code: J0256

Description: Alpha 1 proteinase inhibitor

Unit: 10 mg

Payment: $4.806

Pay quarter: Q4 2023

Dosage and Frequency

Alpha-1 Antitrypsin Deficiency

• 60mg/kg IV every 1 week

Calculate drug reimbursement

Patient dosage

Patient insurance

Total Reimbursement:

$2,306.88

(ASP: $2,176.30, Margin: $130.58)

Code:

J0256

# Units to bill:

480

Prior Authorization

Prior auth criteria for Prolastin-C may include but is not limited to:

1. Documentation of a diagnosis of alpha-1 antitrypsin deficiency (AATD).
2. Documentation of a serum alpha-1 antitrypsin level of less than or equal to 11 micromoles/L (110 mg/dL).
3. Documentation of the absence of active liver disease or evidence of hepatic dysfunction.
4. Documentation of an appropriate trial of augmentation therapy with weekly infusions of Pralastin-C for at least 3 months.
5. Documentation of a benefit from augmentation therapy with weekly infusions of Pralastin-C.
6. Documentation of a documented hypersensitivity to Pralastin-C or any of its components.
7. Documentation of compliance with all other applicable Pralastin-C prescribing information.

Insurance prior auth guidelines:

Billable NDCs

00053-7201-02

Zemaira (CSL BEHRING LLC)

1 MG

00944-2814-01

Aralast NP (TAKEDA PHARMACEUTICALS AMERICA, INC.)

1 MG