Givlaari (givosiran)
Billing
Code: J0223
Description: Inj givosiran 0.5 mg
Unit: 0.5 mg
Payment: $112.486
Pay quarter: Q3 2023
Dosage and Frequency
Acute Hepatic Porphyria (AHP)
• 2.5mg/kg SQ every 1 month
• 2.5mg/kg SQ every 1 month
Calculate drug reimbursement
Total Reimbursement:
$47,694.06(ASP: $44,994.40, Margin: $2,699.66)
Code:
J0223# Units to bill:
400Prior Authorization
Prior auth criteria for Givlaari 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 polyneuropathy due to hereditary transthyretin-mediated amyloidosis (hATTR) by a specialist in the appropriate field.
3. The patient must have been determined to be clinically appropriate for Givlaari therapy by a specialist in the appropriate field.
4. The patient must have failed to respond adequately to other treatments, if any, for hATTR.
5. The patient must not have a known hypersensitivity to any of the components of Givlaari.
6. The patient must not be pregnant or lactating.
7. The patient must not have a known history of severe hepatic impairment.
8. The patient must not have a history of alcohol or drug abuse or dependence.
9. The patient must not be enrolled in a clinical trial or have received Givlaari in the past.
10. The patient must not have received a liver transplant.
Insurance prior auth guidelines:
Billable NDCs
71336-1001-01
Givlaari (ALNYLAM PHARMACEUTICALS, INC.)
189 MG
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