Does J0485 require prior authorization?

Yes, J0485 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0485?

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

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`J0485`, Injection, belatacept, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted, and for DMEPOS base items requiring WOPD the supplier must have a signed WOPD prior to delivery.
Suppliers must maintain proof of delivery (POD) documentation in their files and produce POD upon request by the Medicare contractor.

For refills of DMEPOS items and supplies, suppliers must contact the beneficiary and document an affirmative response prior to dispensing the refill, and this contact must occur no sooner than 30 calendar days prior to the expected end of the current supply.

Treating practitioners billing for drugs must be enrolled as DMEPOS suppliers with the National Supplier Clearinghouse and must be authorized by the state to dispense drugs; documentation of enrollment and state dispensing authority is required.

Key Coverage Criteria

Immunosuppressive drugs are covered when FDA-approved and the approved labeling includes an indication for preventing or treating rejection of a transplanted organ or tissue.
Immunosuppressive drugs are covered when FDA-approved and the labeling indicates use in conjunction with immunosuppressive drugs to prevent or treat transplant rejection.
Immunosuppressive drugs are covered when FDA-approved and the DME MAC, in processing a Medicare claim, determines the drug is reasonable and necessary to prevent or treat rejection or to be used in conjunction with such drugs.
Compounded formulations derived solely from FDA-approved immunosuppressive drugs are covered when administered orally or enterally.
Dosage, frequency, and route of administration must conform to generally accepted medical practice and be medically necessary to prevent or treat organ transplant rejection.
Drugs that meet the above criteria are covered irrespective of whether they can be self-administered, subject to other policy limitations.

18 Active Policies

FLORIDA_BLUE-FLBLUE-NULOJIX-BELATACEPT-7C858ECE93, Nulojix (belatacept)

HEALTHPARTNERS-CC-ENTRY-203023, Belatacept (Nulojix) – Minnesota Health Care Programs

MULTI

BCBSND-BELATACEPT-NULOJIX-093C21C858, Belatacept Nulojix

BCBSNE-X-219-6E8037A8A2, NULOJIX

BCBSNJ-DRUGS-095-5DDEA30204, Belatacept (Nulojix)

HEALTHNET_OR-HNOR-BELATACEPT-NULOJIX-CP-PHAR-201-89A595B2F8, Belatacept (Nulojix); CP.PHAR.201

BCBSNM-RX501.158, Belatacept

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.158, Belatacept

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

EVICORE-MEDICAL_DRUG-DE5BDCFE3343, Nulojix (belatacept)

L33824, Immunosuppressive Drugs

PREMERA-5-01-536-NULOJIX-BELATACEPT-FOR-ADULTS-F7700F5958, 5.01.536 Nulojix (belatacept) for Adults

AETNA-CPB-0493, Kidney Transplantation

BCBSIL-RX501.158, Belatacept

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.158, Belatacept

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

`J0485`, Injection, belatacept, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

J0485, Injection, belatacept, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

`J0485`, Injection, belatacept, 1 mg