Trogarzo (ibalizumab-uiyk)
Billing
Code: J1746
Description: Inj., ibalizumab-uiyk, 10 mg
Unit: 10 mg
Payment: $74.292
Pay quarter: Q3 2023
Dosage and Frequency
Human Immunodeficiency Virus Type 1 (HIV-1)
Loading dose:
• 2000mg IV
Maintenance:
• 800 mg every 2 weeks
Loading dose:
• 2000mg IV
Maintenance:
• 800 mg every 2 weeks
Calculate drug reimbursement
Total Reimbursement:
$6,299.96(ASP: $5,943.36, Margin: $356.60)
Code:
J1746# Units to bill:
80Prior Authorization
Prior auth criteria for Trogarzo may include but is not limited to:
1. The patient must be 18 years of age or older.
2. The patient must have HIV-1 infection that has been confirmed by laboratory testing.
3. The patient must have HIV-1 infection that is virologically suppressed (HIV-1 RNA <50 copies/mL) on a stable antiretroviral regimen for at least 6 months.
4. The patient must not have had any previous treatment failure with an INSTI-based regimen.
5. The patient must not have any major mutation associated with resistance to INSTI-based antiretroviral regimens.
6. The patient must not have a known hypersensitivity to Trogarzo or any of its components.
7. The patient must not have any ongoing or active drug or alcohol abuse.
8. The patient must not have any current or history of hepatitis B or C infection.
9. The patient must not have any contraindications to Trogarzo as listed in the prescribing information.
Insurance prior auth guidelines:
Billable NDCs
62064-0122-02
Trogarzo (THERATECHNOLOGIES INC.)
400 MG
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