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Ruxience (rituximab-pvvr)


Code: Q5119

Description: Inj ruxience, 10 mg

Unit: 10 mg

Payment: $22.304

Pay quarter: Q4 2023

Medicare history

Dosage and Frequency

Rheumatoid Arthritis (RA)

• Two 1000mg IV doses separated by 2 weeks, every 6 months

Calculate drug reimbursement

Total Reimbursement:


(ASP: $2,104.15, Margin: $126.25)



# Units to bill:


Prior Authorization

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

1. Patient must be at least 18 years of age.
2. Patient must have a diagnosis of a chronic, non-cancer pain condition, such as osteoarthritis, fibromyalgia, or neuropathic pain.
3. The patient must have tried and failed at least two different classes of medications for the condition prior to requesting Ruxience.
4. The patient must not have any contraindications to the use of Ruxience, such as any known hypersensitivity or allergy to the active ingredients.
5. The patient must have a valid prescription from a licensed healthcare provider.
6. The patient must not have any active substance abuse issues.
7. The patient must have documentation of an established relationship with the prescribing healthcare provider.
8. The patient must not have any known history of adverse reactions to Ruxience or its active ingredients.
9. The patient must have an acceptable plan of care that includes appropriate monitoring and review of the patient's response to the Ruxience regimen.
10. The patient must not be pregnant or nursing.

Insurance prior auth guidelines:


United Healthcare



Billable NDCs


Ruxience (PFIZER INC.)

100 MG


Ruxience (PFIZER INC.)

500 MG



Drug Enrollment Form