Drug IndexFlebogamma (IVIG)
Billing
Code: J1572
Description: N/A
Unit: N/A
Payment: Claims for J1572 must be manually adjudicated
Pay quarter: N/A
Covered in Part D: Yes
Avg tier level: 4
Drug Cost
Calculate drug cost and reimbursement
Total WAC:
$3,176.40Total Reimbursement:
N/A(ASP: N/A, Margin: N/A)
.
.# Units to bill:
N/ADosage & Frequency
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
Prior Authorization
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