Provenge (Sipuleucel-T)
Billing
Code: Q2043
Description: Sipuleucel-t auto cd54+
Unit: 1 infusion
Payment: $53062.441
Pay quarter: Q3 2023
Dosage and Frequency
Prostate cancer
• One dose IV every 2 weeks for 3 doses
• One dose IV every 2 weeks for 3 doses
Calculate drug reimbursement
Total Reimbursement:
$56,246.19(ASP: $53,062.44, Margin: $3,183.75)
Code:
Q2043# Units to bill:
1Prior Authorization
Prior auth criteria for Provenge may include but is not limited to:
1. Documented history of metastatic castrate-resistant prostate cancer (mCRPC) as confirmed by a biopsy or imaging
2. Patient is asymptomatic or mildly symptomatic
3. ECOG performance status of 0 or 1
4. Prostate specific antigen (PSA) ? 5 ng/mL
5. Duration of disease ? 2 years
6. No prior chemotherapy or other anti-cancer therapy
7. Adequate hematologic, hepatic, and renal function
8. Adequate coagulation parameters
9. No active autoimmune disease
Insurance prior auth guidelines:
Billable NDCs
30237-8900-06
PROVENGE (DENDREON PHARMACEUTICALS LLC)
0 Per infusion (minimum 50 million cells)
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