Gammagard liquid (IVIG)
Billing
Code: J1569
Description: Gammagard liquid injection
Unit: 0.5 g
Payment: $46.031
Pay quarter: Q3 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$2,927.57(ASP: $2,761.86, Margin: $165.71)
Code:
J1569# Units to bill:
60Prior 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
GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)
1000 MG
00944-2700-03
GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)
2500 MG
00944-2700-04
GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)
5000 MG
00944-2700-05
GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)
10000 MG
00944-2700-06
GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)
20000 MG
00944-2700-07
GAMMAGARD LIQUID (TAKEDA PHARMACEUTICALS AMERICA, INC.)
30000 MG
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