Flebogamma - CuraFi

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Flebogamma (IVIG)

Billing

Code: J1572

Description: Flebogamma injection

Unit: 0.5 g

Payment: $56.116

Pay quarter: Q3 2023

Dosage and Frequency

Calculate drug reimbursement

Patient dosage

Patient insurance

Total Reimbursement:

$3,568.98

(ASP: $3,366.96, Margin: $202.02)

Code:

J1572

# Units to bill:

Prior Authorization

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

1. The patient must be age 18 or older.
2. The patient must have been diagnosed with an immune thrombocytopenic purpura (ITP).
3. The patient must have failed or not tolerated other treatments.
4. The patient must not have any active infections or severe thrombocytopenia.
5. The patient must have a platelet count of less than 30,000/mm3.
6. The patient must not have received Flebogamma within the past 6 months.
7. The patient must be willing to participate in a patient registry.

Insurance prior auth guidelines:

Billable NDCs

61953-0004-02

Flebogamma DIF (GRIFOLS USA, LLC)

2500 MG

61953-0004-03

Flebogamma DIF (GRIFOLS USA, LLC)

5000 MG