Riabni (rituximab-arrx)
Billing
Code: Q5123
Description: Inj. riabni, 10 mg
Unit: 10 mg
Payment: $49.750
Pay quarter: Q1 2023
Dosage and Frequency
Rheumatoid Arthritis (RA)
• Two 1000mg IV doses separated by 2 weeks, every 6 months
• Two 1000mg IV doses separated by 2 weeks, every 6 months
Calculate drug reimbursement
Total Reimbursement:
$5,273.50(ASP: $4,975.00, Margin: $298.50)
Code:
Q5123# Units to bill:
100Prior Authorization
Prior auth criteria for Riabni may include but is not limited to:
1. The requested medication must be medically necessary for the diagnosis and condition being treated.
2. The requesting provider must be legally authorized to prescribe the medication.
3. The patient must have tried and failed a generic or lower cost equivalent drug prior to requesting the requested medication.
4. The request must include the patient’s diagnosis, age, and weight.
5. The request must include the medication name, dosage, and frequency of administration.
6. The request must include laboratory or other diagnostic test results related to the patient’s condition.
7. The request must include a specific treatment plan with measurable goals.
8. The request must include a signed and dated form with the prescriber’s signature.
9. The request must include a signed and dated treatment agreement form with the patient’s signature.
10. The request must include a signed and dated informed consent form with the patient’s signature.
Insurance prior auth guidelines:
Billable NDCs
55513-0224-01
Riabni (AMGEN USA, INC.)
100 MG
55513-0326-01
Riabni (AMGEN USA, INC.)
500 MG
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