Drug IndexProlastin-C (A1-PI)



Billing

Code: J0256

Description: Alpha 1 proteinase inhibitor

Unit: 10 MG

Payment: $4.883

Pay quarter: Q1 2024


Covered in Part D: Yes

Avg tier level: 4


Drug Cost

Calculate drug cost and reimbursement


Total WAC:

$2,688.00

Total Reimbursement:

$2,343.84

(ASP: $2,211.17, Margin: $132.67)

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# Units to bill:

480

Dosage & Frequency

Alpha-1 Antitrypsin Deficiency

• 60mg/kg IV every 1 week


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


13533-0705-01

Prolastin-C (GRIFOLS USA, LLC)

1 MG



Prior Authorization

Aetna

United Healthcare

Anthem

Cigna


Resources

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