Drug IndexProlastin-C (Alpha1-Proteinase Inhibitor (Human))


Billing

Code: J0256

Description: Alpha 1 proteinase inhibitor

Unit: 10 MG

Payment: $4.935

Pay quarter: Q4 2024

Covered in Part D: Yes

Avg tier level: 4

Drug Cost

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Total WAC:

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Total Reimbursement:

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# Units to bill:

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Billable NDCs

13533-0700-02

Prolastin-C (Grifols USA, LLC)

1 KIT in 1 CARTON (13533-700-02) * 20 mL in 1 VIAL, SINGLE-DOSE (13533-702-11) * 20 mL in 1 VIAL, SINGLE-DOSE (13533-000-06)


13533-0703-10

Prolastin-C (Grifols USA, LLC)

1 KIT in 1 CARTON (13533-703-10) * 20 mL in 1 VIAL, SINGLE-DOSE (13533-702-11) * 20 mL in 1 VIAL, SINGLE-DOSE (13533-200-20)


13533-0705-01

Prolastin-C (Grifols USA, LLC)

1 VIAL in 1 CARTON (13533-705-01) / 20 mL in 1 VIAL (13533-705-11)


13533-0705-31

Prolastin-C (Grifols USA, LLC)

1 VIAL in 1 CARTON (13533-705-31) / 10 mL in 1 VIAL (13533-705-32)


13533-0705-51

Prolastin-C (Grifols USA, LLC)

1 VIAL in 1 CARTON (13533-705-51) / 80 mL in 1 VIAL (13533-705-52)


13533-0706-22

Prolastin-C (Grifols USA, LLC)

1 KIT in 1 CARTON (13533-706-22) * 20 mL in 1 VIAL, SINGLE-DOSE (13533-702-11) * 20 mL in 1 VIAL, SINGLE-DOSE (76297-002-22)


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