Avsola (infliximab-axxq)
Billing
Code: Q5121
Description: Inj. avsola, 10 mg
Unit: 10 mg
Payment: $33.502
Pay quarter: Q1 2023
Dosage and Frequency
Crohn's Disease (CD)
Ulcerative Colitis (UC)
Ankylosing Spondylitis (AS)
Psoriatic Arthritis (PsA)
Plaque Psoriasis (Ps)
Induction:
• 5mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 5mg/kg IV every 8 weeks
Ulcerative Colitis (UC)
Ankylosing Spondylitis (AS)
Psoriatic Arthritis (PsA)
Plaque Psoriasis (Ps)
Induction:
• 5mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 5mg/kg IV every 8 weeks
Rheumatoid Arthritis (RA)
Induction:
• 3mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 3mg/kg IV every 8 weeks
Induction:
• 3mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 3mg/kg IV every 8 weeks
Calculate drug reimbursement
Total Reimbursement:
$1,065.36(ASP: $1,005.06, Margin: $60.30)
Code:
Q5121# Units to bill:
30Prior Authorization
Prior auth criteria for Avsola may include but is not limited to:
1. Patients must meet the criteria for a diagnosis of a chronic condition as listed in the Avsola product labeling.
2. Patients must have tried and failed, or have an contraindication to, an appropriate alternative therapy.
3. Patients must have a medically appropriate and documented response to a trial of therapy with Avsola.
4. The treatment plan must be medically necessary and appropriate for the patient’s condition.
5. The patient’s medical record must include documentation of the patient’s response to the trial of Avsola and other treatment regimens.
6. The patient must be 18 years of age or older.
7. The prescribing physician must be a board-certified or board-eligible physician in the United States with a valid, unrestricted license.
8. The prescribing physician must have adequate experience and knowledge of the patient’s condition to make an informed judgment about the potential risks and benefits of prescribing Avsola for the patient.
Insurance prior auth guidelines:
Billable NDCs
55513-0670-01
Avsola (AMGEN USA, INC.)
100 MG
Resources