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Zip Home Phone Cell / Other Phone Please attach front and back copy of patient s insurance cards. Medical Information Diagnosis: o Alpha1 Antitrypsin De ciency 273.4 o Panacinar Emphysema 492.8 o Other AAT Phenotype: FEV1 % predicted Serum AAT Level mg/dL or M Weight.

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HCPCS coding for ZEMAIRA should use: J0256: Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg For Medicare beneficiaries, the following code may not be payable. The code selected is based on the documented service provided to the patient.

Last updated on Feb 14, 2023. The Prolastin brand name has been discontinued in the U.S. If generic versions of this product have been approved by the FDA, there may be generic equivalents available.

This may be at home, at work, at an infusion center, or even when you are traveling. If you receive your infusions at home, your PROLASTIN-C LIQUID will be delivered directly to your home prior to your appointment with your infusion nurse.

The cost for Prolastin-C intravenous powder for injection human is around $10 for a supply of 1 powder for injection, depending on the pharmacy you visit. Quoted prices are for cash-paying customers and are not valid with insurance plans....Intravenous Powder For Injection. QuantityPer unitPrice1$10.04$10.04

PROLASTIN-C LIQUID is available only through the PROLASTIN DIRECT program. To help you get started, speak with a Patient Service Coordinator by calling 1-800-305-7881.

What is the difference between PROLASTIN-C and PROLASTIN-C LIQUID? PROLASTIN-C LIQUID is the same medicine you have been receiving in a lyophilized (powder) formulation, but is now available in a convenient, ready-to-infuse liquid formulation.

Do Medicare prescription drug plans cover Prolastin C? Yes. 98% of Medicare prescription drug plans cover this drug.

PROLASTIN-C LIQUID is available only through the PROLASTIN DIRECT program. To order, call 1-800-305-7881.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232