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Pulmozyme (dornase alfa)


Code: J7639

Description: Dornase alfa non-comp unit

Unit: 1 mg

Payment: $52.254

Pay quarter: Q4 2023

Medicare history

Dosage and Frequency

Cystic Fibrosis (CF)

• 2.5mg once daily

Calculate drug reimbursement

Total Reimbursement:


(ASP: $123.24, Margin: $7.39)



# Units to bill:


Prior Authorization

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

1. The patient must have a confirmed diagnosis of cystic fibrosis (CF) as established by two genetic tests.

2. The patient must be at least 6 years of age.

3. The patient must have a forced expiratory volume in 1 second (FEV1) of ? 40%.

4. The patient must have a FEV1 decline of ? 10% from baseline in the past year (or two consecutive measurements 6 months apart).

5. The patient must have evidence of ongoing pulmonary exacerbations requiring antibiotics or other treatments.

6. The patient must have an FEV1 that is not expected to improve substantially with bronchodilator therapy.

7. The patient must not have had a lung transplant or have a life expectancy of less than 6 months.

Insurance prior auth guidelines:

Billable NDCs


Pulmozyme (GENENTECH, INC.)

75 MG