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Gamunex-C (IVIG)


Billing

Code: J1561

Description: Gamunex-c/gammaked

Unit: 0.5 g

Payment: $47.796

Pay quarter: Q1 2023


Medicare history

Dosage and Frequency

Calculate drug reimbursement


Total Reimbursement:

$3,039.83

(ASP: $2,867.76, Margin: $172.07)


Code:

J1561

# Units to bill:

60

Prior Authorization

Prior auth criteria for Gamunex-C may include but is not limited to:


1. The patient must be 18 years of age or older.
2. The patient must have been diagnosed with primary immunodeficiency disorder (PIDD).
3. The patient must have failed or not tolerated at least two immunoglobulin intravenous (IVIG) or subcutaneous (SCIG) regimens.
4. The patient must not have any contraindications to Gamunex-C, including: history of anaphylaxis to human immune globulin, IgA deficiency with antibodies to IgA, and selective IgA deficiency.
5. The patient must not have any active infection.
6. The patient must not have any history of thrombosis or increased risk of thrombosis.
7. The patient must not have any other medical condition that could interfere with the absorption, metabolism, or excretion of Gamunex-C.
8. The patient must not have any known hypersensitivity to any component of the product.
9. The patient must not have any history of non-compliance with therapy.
10. The patient must not have any history of drug or alcohol abuse.


Insurance prior auth guidelines:


Billable NDCs

13533-0800-12

Gamunex-C (GRIFOLS USA, LLC)

1000 MG


13533-0800-15

Gamunex-C (GRIFOLS USA, LLC)

2500 MG


13533-0800-20

Gamunex-C (GRIFOLS USA, LLC)

5000 MG


13533-0800-24

Gamunex-C (GRIFOLS USA, LLC)

20000 MG


13533-0800-40

Gamunex-C (GRIFOLS USA, LLC)

40000 MG


13533-0800-71

Gamunex-C (GRIFOLS USA, LLC)

10000 MG


76125-0900-10

GAMMAKED (KEDRION BIOPHARMA, INC.)

10000 MG


76125-0900-20

GAMMAKED (KEDRION BIOPHARMA, INC.)

20000 MG


76125-0900-50

GAMMAKED (KEDRION BIOPHARMA, INC.)

5000 MG



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