Drug IndexGammaplex (Immune Globulin Intravenous (Human))


Billing

Code: J1557

Description: Gammaplex injection

Unit: 500 MG

Payment: $57.925

Pay quarter: Q4 2024

Covered in Part D: Yes

Avg tier level: 4

Drug Cost

Calculate drug cost and reimbursement


Total WAC:

N/A

Total Reimbursement:

N/A

(ASP: N/A, Margin: N/A)

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# Units to bill:

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Billable NDCs

64208-8234-06

Gammaplex (BPL)

1 BOTTLE, GLASS in 1 CARTON (64208-8234-6) / 100 mL in 1 BOTTLE, GLASS (64208-8234-2)


64208-8234-07

Gammaplex (BPL)

1 BOTTLE, GLASS in 1 CARTON (64208-8234-7) / 200 mL in 1 BOTTLE, GLASS (64208-8234-3)


64208-8234-08

Gammaplex (BPL)

1 BOTTLE, GLASS in 1 CARTON (64208-8234-8) / 400 mL in 1 BOTTLE, GLASS (64208-8234-4)


64208-8235-05

Gammaplex (BPL)

1 BOTTLE, GLASS in 1 CARTON (64208-8235-5) / 50 mL in 1 BOTTLE, GLASS (64208-8235-1)


64208-8235-06

Gammaplex (BPL)

1 BOTTLE, GLASS in 1 CARTON (64208-8235-6) / 100 mL in 1 BOTTLE, GLASS (64208-8235-2)


64208-8235-07

Gammaplex (BPL)

1 BOTTLE, GLASS in 1 CARTON (64208-8235-7) / 200 mL in 1 BOTTLE, GLASS (64208-8235-3)


Prior Authorization

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