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Provenge (Sipuleucel-T)


Billing

Code: Q2043

Description: Sipuleucel-t auto cd54+

Unit: 1 infusion

Payment: $53472.873

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Prostate cancer

• One dose IV every 2 weeks for 3 doses

Calculate drug reimbursement


Total Reimbursement:

$53,472.87

(ASP: $50,446.11, Margin: $3,026.77)


Code:

Q2043

# Units to bill:

1

Prior Authorization

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


1. Documented history of metastatic castrate-resistant prostate cancer (mCRPC) as confirmed by a biopsy or imaging
2. Patient is asymptomatic or mildly symptomatic
3. ECOG performance status of 0 or 1
4. Prostate specific antigen (PSA) ? 5 ng/mL
5. Duration of disease ? 2 years
6. No prior chemotherapy or other anti-cancer therapy
7. Adequate hematologic, hepatic, and renal function
8. Adequate coagulation parameters
9. No active autoimmune disease


Insurance prior auth guidelines:

Aetna

Anthem


Billable NDCs

30237-8900-06

PROVENGE (DENDREON PHARMACEUTICALS LLC)

0 Per infusion (minimum 50 million cells)



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