Panzyga (IVIG)
Billing
Code: J1576
Description: Inj, panzyga, 500 mg
Unit: 0.5 g
Payment: $65.741
Pay quarter: Q3 2023
Dosage and Frequency
Calculate drug reimbursement
Total Reimbursement:
$4,181.13(ASP: $3,944.46, Margin: $236.67)
Code:
J1576# Units to bill:
60Prior Authorization
Prior auth criteria for Panzyga may include but is not limited to:
1. The patient must have a diagnosis of primary immunodeficiency (PID)
2. The patient must meet the criteria for one of the following conditions:
* Common variable immunodeficiency
* X-linked agammaglobulinemia
* Severe combined immunodeficiency
* Wiskott-Aldrich syndrome
* Chronic granulomatous disease
* Hyper IgM syndrome
3. The patient must have failed to respond to or is intolerant to conventional therapy
4. The requested dose must be appropriate for the patient's weight
5. The patient must have a signed consent form indicating their understanding of the risks and benefits of treatment
6. The patient must have a negative pregnancy test if they are of childbearing potential
7. The patient must have a serum IgG level ?400 mg/dL
8. The patient must have evidence of an active infection or an increased risk of infection
Insurance prior auth guidelines:
Billable NDCs
00069-1109-02
PANZYGA (PFIZER INC.)
2500 MG
00069-1224-02
PANZYGA (PFIZER INC.)
5000 MG
00069-1312-02
PANZYGA (PFIZER INC.)
10000 MG
00069-1415-02
PANZYGA (PFIZER INC.)
20000 MG
00069-1558-02
PANZYGA (PFIZER INC.)
30000 MG
68982-0820-02
PANZYGA (PFIZER INC.)
2500 MG
68982-0820-04
PANZYGA (PFIZER INC.)
10000 MG
68982-0820-05
PANZYGA (PFIZER INC.)
20000 MG
68982-0820-06
PANZYGA (PFIZER INC.)
30000 MG
68982-0822-02
PANZYGA (OCTAPHARMA)
2500 MG
68982-0822-03
PANZYGA (OCTAPHARMA)
5000 MG
68982-0822-04
PANZYGA (OCTAPHARMA)
10000 MG
68982-0822-05
PANZYGA (OCTAPHARMA)
20000 MG
68982-0822-06
PANZYGA (OCTAPHARMA)
30000 MG
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