Active substance: Lifitegrast
Xiidra (Lifitegrast) NDC 0078-0911 converts to 00078-0911-12 for billing and bills under J3490 at Per Administration.
Calculate the exact number of billable HCPCS units to report on CMS-1500 / 837P claims based on the patient dose and single-dose vial waste.
| Formulation / role | Package NDC | Product NDC | 11-digit HIPAA | Packaging detail | Copy |
|---|---|---|---|---|---|
| 50 mg/mL | 24208-911-12 | 24208-911 | 24208-0911-12 | 12 POUCH in 1 CARTON (24208-911-12) / 5 AMPULE in 1 POUCH (24208-911-05) / .2 mL in 1 AMPULE | |
| Inner component | 24208-911-05 | 24208-911 | 24208-0911-05 | Inner component of kit (24208-911-12) | |
| 50 mg/mL | 24208-911-94 | 24208-911 | 24208-0911-94 | 4 POUCH in 1 CARTON (24208-911-94) / 5 AMPULE in 1 POUCH (24208-911-95) / .2 mL in 1 AMPULESample | |
| Inner component | 24208-911-95 | 24208-911 | 24208-0911-95 | Inner component of kit (24208-911-94) | |
| 50 mg/mL | 0078-0911-12 | 0078-0911 | 00078-0911-12 | 12 POUCH in 1 CARTON (0078-0911-12) / 5 AMPULE in 1 POUCH (0078-0911-05) / .2 mL in 1 AMPULE | |
| Inner component | 0078-0911-05 | 0078-0911 | 00078-0911-05 | Inner component of kit (0078-0911-12) | |
| 50 mg/mL | 0078-0911-94 | 0078-0911 | 00078-0911-94 | 4 POUCH in 1 CARTON (0078-0911-94) / 5 AMPULE in 1 POUCH (0078-0911-95) / .2 mL in 1 AMPULESample | |
| Inner component | 0078-0911-95 | 0078-0911 | 00078-0911-95 | Inner component of kit (0078-0911-94) |
Taken from the manufacturer's FDA Structured Product Labeling submission. This is the label as filed, not a summary.