Drug IndexPulmozyme (Dornase Alfa)



Billing

Code: J7639

Description: Dornase alfa non-comp unit

Unit: 1 MG

Payment: $52.034

Pay quarter: Q2 2024


Covered in Part D: Yes

Avg tier level: 4


Drug Cost

Calculate drug cost and reimbursement


Total WAC:

N/A

Total Reimbursement:

N/A

(ASP: N/A, Margin: N/A)

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# Units to bill:

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Billable NDCs

50242-0100-40

Pulmozyme (Genentech, Inc.)

5 POUCH in 1 CARTON (50242-100-40) / 6 AMPULE in 1 POUCH (50242-100-39) / 2.5 mL in 1 AMPULE



Prior Authorization


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