Flebogamma (IVIG)
Billing
Code: J1572
Description: Flebogamma injection
Unit: 0.5 g
Payment: $41.534
Pay quarter: Q1 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$2,641.56(ASP: $2,492.04, Margin: $149.52)
Code:
J1572# Units to bill:
60Prior 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
61953-0004-04
Flebogamma DIF (GRIFOLS USA, LLC)
10000 MG
61953-0004-05
Flebogamma DIF (GRIFOLS USA, LLC)
20000 MG
61953-0005-01
FLEBOGAMMA 10% DIF (GRIFOLS USA, LLC)
5000 MG
61953-0005-02
FLEBOGAMMA 10% DIF (GRIFOLS USA, LLC)
10000 MG
61953-0005-03
FLEBOGAMMA 10% DIF (GRIFOLS USA, LLC)
20000 MG
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