Gammagard liquid

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Gammagard liquid (IVIG)

Billing

Code: J1569

Description: Gammagard liquid injection

Unit: 0.5 g

Payment: $45.551

Pay quarter: Q1 2023

Dosage and Frequency

Calculate drug reimbursement

Patient dosage

Patient insurance

Total Reimbursement:

$2,897.04

(ASP: $2,733.06, Margin: $163.98)

Code:

J1569

# Units to bill:

Prior Authorization

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

1. The patient must be over the age of two.
2. The patient must have a diagnosis of primary immunodeficiency, as defined by the World Health Organization (WHO).
3. The patient must not have any contraindications to intravenous immunoglobulin therapy.
4. The patient must have had an inadequate response to other therapies, such as antibiotics, antifungal medications, or other immunomodulatory agents.
5. The patient must have had an inadequate response to oral immunoglobulin therapy.
6. The patient must have laboratory evidence of hypogammaglobulinemia.
7. The patient must have an increased risk of recurrent infections.
8. The patient must not have any known allergy to Gammagard Liquid or any of its components.

Insurance prior auth guidelines:

Billable NDCs

00944-2700-02