Drug IndexZolgensma (onasemnogene abeparvovec-xioi)
Billing
Code: J3399
Description: N/A
Unit: N/A
Payment: Claims for J3399 must be manually adjudicated
Pay quarter: N/A
Covered in Part D: No
Drug Cost
Calculate drug cost and reimbursement
Total WAC:
$2,254,412.00Total Reimbursement:
N/A(ASP: N/A, Margin: N/A)
.
.# Units to bill:
N/ADosage & Frequency
• 1.1 x 10^14 vector genomes per kg IV
Billable NDCs
71894-0120-02
Zolgensma 2x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0121-03
Zolgensma 2x5.5 mL vial and 1x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0122-03
Zolgensma 1x5.5 mL vial and 2x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0123-03
Zolgensma 3x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0124-04
Zolgensma 2x5.5 mL vial and 2x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0125-04
Zolgensma 1x5.5 mL vial and 3x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0126-04
Zolgensma 4x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0127-05
Zolgensma 2x5.5 mL vial and 3x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0128-05
Zolgensma 1x5.5 mL vial and 4x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0129-05
Zolgensma 5x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0130-06
Zolgensma 2x5.5 mL vial and 4x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0131-06
Zolgensma 1x5.5 mL vial and 5x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0132-06
Zolgensma 6x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0133-07
Zolgensma 2x5.5 mL vial and 5x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0134-07
Zolgensma 1x5.5 mL vial and 6x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0135-07
Zolgensma 7x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0136-08
Zolgensma 2x5.5 mL vial and 6x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0137-08
Zolgensma 1x5.5 mL vial and 7x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0138-08
Zolgensma 8x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0139-09
Zolgensma 2x5.5 mL vial and 7x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0140-09
Zolgensma 1x5.5 mL vial and 9x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
71894-0141-09
Zolgensma 9x8.3 mL vial Kit (AVEXIS)
0 per tx dose (up to 5 x10^15 vg?)
Prior Authorization
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