Ferrlecit (Sodium ferric gluconate complex)
Billing
Code: J2916
Description: Na ferric gluconate complex
Unit: 12.5 mg
Payment: $2.123
Pay quarter: Q3 2023
Dosage and Frequency
Iron Deficiency Anemia (IDA)
• 125mg IV
• 1.5mg/kg IV for pediatric patients
• 125mg IV
• 1.5mg/kg IV for pediatric patients
Calculate drug reimbursement
Total Reimbursement:
$22.50(ASP: $21.23, Margin: $1.27)
Code:
J2916# Units to bill:
10Prior Authorization
Prior auth criteria for Ferrlecit may include but is not limited to:
1. Ferrlecit is indicated for the treatment of iron deficiency anemia in adult patients with non-dialysis dependent chronic kidney disease (CKD).
2. Ferrlecit is indicated for the treatment of iron deficiency anemia in adult patients who have had inadequate response to oral iron therapy.
3. Ferrlecit is indicated for the treatment of iron deficiency anemia in adult patients who are intolerant to oral iron therapy.
4. Ferrlecit must be prescribed by a physician who is familiar with the management of CKD and anemia.
5. Ferrlecit should be used only in patients who have demonstrated an inadequate response to or intolerance of oral iron therapy.
6. Ferrlecit should be used only when the potential benefit of the intravenous iron therapy is expected to outweigh the potential risks.
7. Ferrlecit should not be used in patients with an active infection.
8. Ferrlecit should not be used in patients with known hypersensitivity to iron dextran or other ingredients of Ferrlecit.
Insurance prior auth guidelines:
Billable NDCs
00024-2792-10
Ferrlecit (SANOFI-AVENTIS)
625 MG
00024-2794-10
Ferrlecit (SANOFI-AVENTIS)
625 MG
00143-9298-10
SODIUM FERRIC GLUCONATE (HIKMA PHARMACEUTICALS USA INC.)
625 MG
00143-9570-10
SODIUM FERRIC GLUCONATE (HIKMA PHARMACEUTICALS USA INC.)
625 MG
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