Prolastin-C (A1-PI)
Billing
Code: J0256
Description: Alpha 1 proteinase inhibitor
Unit: 10 mg
Payment: $4.592
Pay quarter: Q1 2023
Dosage and Frequency
Alpha-1 Antitrypsin Deficiency
• 60mg/kg IV every 1 week
• 60mg/kg IV every 1 week
Calculate drug reimbursement
Total Reimbursement:
$2,336.41(ASP: $2,204.16, Margin: $132.25)
Code:
J0256# Units to bill:
480Prior Authorization
Prior auth criteria for Prolastin-C may include but is not limited to:
Insurance prior auth guidelines:
Billable NDCs
00053-7201-02
Zemaira (CSL BEHRING LLC)
1 MG
00944-2814-01
Aralast NP (TAKEDA PHARMACEUTICALS AMERICA, INC.)
1 MG
00944-2815-01
Aralast NP (TAKEDA PHARMACEUTICALS AMERICA, INC.)
1 MG
13533-0703-10
Prolastin-C (GRIFOLS USA, LLC)
1 MG
13533-0705-01
Prolastin-C (GRIFOLS USA, LLC)
1 MG
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