Does J0257 require prior authorization?

Yes, J0257 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0257?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`J0257`, Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documented pretreatment serum AAT level < 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry).
Documented pretreatment post-bronchodilation FEV1 value ≥ 25% and ≤ 80% of predicted (forced expiratory volume in 1 second, post-bronchodilation).

Key Coverage Criteria

Medically necessary for treatment of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI) in patients who meet all of the following criteria for initial therapy: diagnosis of congenital alpha1-antitrypsin deficiency with specific phenotypes or low AAT level, AAT <11 µmol/L, continued optimal conventional treatment, nonsmoker, emphysema diagnosed by PFT, dosing per FDA labeling, initial authorization max 12 months; continuation requires current therapy, documented positiv [...]
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Aetna considers alpha 1-proteinase inhibitor (e.g., Aralast NP, Glassia, Prolastin-C, and Zemaira) therapy medically necessary for the treatment of emphysema due to alpha 1-antitrypsin (AAT) deficiency when all of the following criteria are met:
The member’s pretreatment serum AAT level is less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);
The member’s pretreatment post-bronchodilation forced expiratory volume in 1 second (FEV1) is greater than or equal to 25% and less than or equal to 80% of the predicted value;
The member has a documented PiZZ, PiZ (null), or Pi (null, null) (homozygous) AAT deficiency or other phenotype or genotype associated with serum AAT concentrations of less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50 mg/dL by nephelometry);

18 Active Policies

ARKBLUE-ALPHA-1-PROTEINASE-INHIBITOR-THERAPY-E-G-ARALAST-1B38F50356, Alpha-1 Proteinase Inhibitor Therapy (e.g., Aralast, Glassia, Prolastin, and Zemaira)

HEALTHPARTNERS-CC-ENTRY-187801, Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: alpha-1 proteinase inhibitor (Aralast NP, Glassia, Prolastin-C, and Zemaira) - Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-AENTRY-045614, Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: alpha-1 proteinase inhibitor (Aralast NP, Glassia, Prolastin-C, and Zemaira)

MULTI

BCBSNJ-DRUGS-014-45021456CA, Alpha 1-Proteinase Inhibitors (Human) [Prolastin-C, Aralast NP, Zemaira, Glassia]

MODA-ALPHA-1-PROTEINASEINHIBITORS-CC26EAEB43, Alpha-1-Proteinase Inhibitors: Aralast NP; Glassia; Prolastin-C; Zemaira

HEALTHNET_OR-HNOR-ALPHA-1-PROTEINASE-INHIBITOR-ARALAST-NP-GLASSIA-PROLASTI-269FA5BB3C, Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira); CP.PHAR.94

IBX-MEDICARE-ADVANTAGE-MA08-050C-67E844D594, Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)

IBX-COMMERCIAL-08-00-91F-35E6FFFBFE, Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-alpha1-proteinase-inhibitors, Alpha1-Proteinase Inhibitors

BCBSTN-3f92956228, Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)

EVICORE-MEDICAL_DRUG-276987012F29, Aralast NP, Glassia, Prolastin-C, and Zemaira (alpha1-proteinase inhibitor [human])

UHC-POL-alpha1-proteinase-inhibitors, Alpha1-Proteinase Inhibitors

AETNA-CPB-0145, Alpha1-Proteinase Inhibitors

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

AMERIHEALTH-COMMERCIAL-08-00-91F-556596BCFF, Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)

SUREST-POL-SUREST-alpha1-proteinase-inhibitors, Alpha1-Proteinase Inhibitors

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-050C-2791A2E230, Alpha-1 Antitrypsin Therapy (e.g., Prolastin-C, Aralast NP, Glassia, Zemaira)

`J0257`, Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

J0257, Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

`J0257`, Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg