Pulmozyme (dornase alfa)
Billing
Code: J7639
Description: Dornase alfa non-comp unit
Unit: 1 mg
Payment: $50.120
Pay quarter: Q1 2023
Dosage and Frequency
Cystic Fibrosis (CF)
• 2.5mg once daily
• 2.5mg once daily
Calculate drug reimbursement
Total Reimbursement:
$132.82(ASP: $125.30, Margin: $7.52)
Code:
J7639# Units to bill:
3Prior Authorization
Prior auth criteria for Pulmozyme may include but is not limited to:
Insurance prior auth guidelines:
Billable NDCs
50242-0100-40
Pulmozyme (GENENTECH, INC.)
75 MG
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