Does J0642 require prior authorization?

Yes, J0642 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0642?

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

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`J0642`, Injection, levoleucovorin (khapzory), 0.5 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

Procedure codes listed are for general reference and may not be all-inclusive.
Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.

Key Coverage Criteria

Coverage of injectable oncology medications is based on NCCN Compendium Categories of Evidence and Consensus (1, 2A, 2B = proven/medically necessary; 3 = unproven/not medically necessary); if NCCN is unavailable, base decisions on FDA labeling.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Oncology medications are medically necessary if (a) the drug is FDA-approved for the oncologic indication and used per FDA labeling, OR (b) the drug has an NCCN Category 1/2A/2B indication per NCCN Guidelines or NCCN Compendium.

14 Active Policies

ARKBLUE-LEVOLEUCOVORIN-CALCIUM-E-G-KHAPZORY-BA532E0F07, Levoleucovorin Calcium (e.g., Khapzory)

BCBSM-2103265-5870FA0FCC, KHAPZORY (LEVOLEUCOVORIN)

BCBSNJ-DRUGS-122-16CFD1DF59, Levoleucovorin (Fusilev and Khapzory)

MODA-LEVOLEUCOVORIN-C8D4EAE94E, Levoleucovorin: Fusilev; Khapzory

BCBSNM-RX502.061, Oncology Medications

BCBSOK-RX502.061, Oncology Medications

UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

BCBSTN-00a3d52f01, Levoleucovorin (Fusilev), Levoleucovorin (Khapzory), Levoleucovorin

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

`J0642`, Injection, levoleucovorin (khapzory), 0.5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

J0642, Injection, levoleucovorin (khapzory), 0.5 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

`J0642`, Injection, levoleucovorin (khapzory), 0.5 mg