Does J1302 require prior authorization?

Yes, J1302 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1302?

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

Backwork Sign up free

`J1302`, Injection, sutimlimab-jome, 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

Documentation of positive clinical response to therapy (e.g., increase in hemoglobin, decreased transfusion requirements, decreased markers of hemolysis, improvement in anemia-related symptoms); and Enjaymo is prescribed by, or in consultation with, a hematologist; and Enjaymo dosing is in accordance with the United States Food and Drug Administration approved labeling; and Patient is not receiving Enjaymo in combination with a complement inhibitor [e.g., eculizumab, Empaveli (pegcetacoplan), Fabhalta (iptacopan), PiaSky (crovalimab), Ultomiris (ravilizumab-cwzb), Zilbrysq (zilucoplan)]; and Reauthorization will be for no more than 12 months
For continuation of therapy, all of the following: o Documentation of positive clinical response to therapy (e.g., increase in hemoglobin, decreased transfusion requirements, decreased markers of hemolysis, improvement in anemia-related symptoms); and o Enjaymo is prescribed by, or in consultation with, a hematologist; and o Enjaymo dosing is in accordance with the United States Food and Drug Administration approved labeling; and o Patient is not receiving Enjaymo in combination with a complement inhibitor [e.g., eculizumab, Empaveli (pegcetacoplan), Fabhalta (iptacopan), PiaSky (crovalimab), Ultomiris (ravilizumab-cwzb), Zilbrysq (zilucoplan)]; and o Reauthorization will be for no more than 12 months
Documentation: prior authorization required by HealthPartners Pharmacy Administration.

Key Coverage Criteria

Adults with CAD may be eligible for sutimlimab-jome (Enjaymo®) when there is chronic hemolysis, positive polyspecific DAT, monospecific DAT for C3d, and cold agglutinin titer ≥64 at 4°C, and the CAD is not secondary to infection, rheumatologic disease, SLE/other autoimmune disorders with ANA, or overt hematologic malignancy.
Enjaymo is indicated for the treatment of hemolysis in adults with cold agglutinin disease (CAD).
Enjaymo is medically necessary for the treatment of CAD in patients who meet all of the following criteria: For initial therapy, all of the following: o Diagnosis of CAD by, or in consultation with, a hematologist with expertise in the diagnosis of CAD; and Confirmation of the CAD diagnosis based on all of the following:  Evidence of chronic hemolysis [e.g., elevated lactated dehydrogenase (LDH), decreased haptoglobin, increased indirect bilirubin, increased ret [...]
Enjaymo is medically necessary for the treatment of CAD in patients who meet all of the following criteria: For initial therapy, all of the following: o Diagnosis of CAD by, or in consultation with, a hematologist with expertise in the diagnosis of CAD; and o Confirmation of the CAD diagnosis based on all of the following:  Evidence of chronic hemolysis [e.g., elevated lactated dehydrogenase (LDH), decreased haptoglobin, increased indirect bilirubin, increased [...]
Indication: confirmed diagnosis of primary cold agglutinin disease.
Indication: patient body weight at least 39 kg prior to initiation of Enjaymo.

20 Active Policies

ARKBLUE-SUTIMLIMAB-JOME-E-G-ENJAYMO-8248891493, Sutimlimab-jome (e.g., Enjaymo)

BCBSLA-00800-FFD08C0D9E, 00800 sutimlimab-jome (Enjaymo)

BCBSM-2159171-4DEE98F9F1, ENJAYMO (SUTIMLIMAB INTRAVENOUS INJECTION)

BCBSMS-S-5-01-585-A717FE249D, State and School Employees' Health Insurance Plan - Enjaymo (sutimlimab-jome)

BCBSMS-L-5-01-585-A99DFB7997, Enjaymo (sutimlimab-jome)

HEALTHPARTNERS-CC-ENTRY-249186, Sutimlimab-jome (Enjaymo)

MULTI

POINT32HEALTH-MDMNG-12751, Enjaymo (sutimlimab-jome)

MULTI

BCBSNE-X-195-122F420D43, ENJAYMO (PREAUTHORIZATION REQUIRED)

MODA-ENJAYMO-44A81E77DB, Enjaymo (sutimlimab-jome)

HEALTHNET_OR-HNOR-SUTIMLIMAB-JOME-ENJAYMO-CP-PHAR-503-D87B78E376, Sutimlimab-jome (Enjaymo); CP.PHAR.503

IBX-COMMERCIAL-08-01-87A-8EE6979156, Sutimlimab-jome (Enjaymo)

IBX-MEDICARE-ADVANTAGE-MA08-145A-647F2940CF, Sutimlimab-jome (Enjaymo)

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

BCBSOK-RX501.180, Sutimlimab-jome

UMR-POL-UMR-enjaymo, Enjaymo (Sutimlimab-Jome)

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

SUREST-POL-SUREST-enjaymo, Enjaymo (Sutimlimab-Jome)

AMERIHEALTH-COMMERCIAL-08-01-87A-60F531FF2A, Sutimlimab-jome (Enjaymo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-145A-F2D90981BC, Sutimlimab-jome (Enjaymo)

BCBSTN-9a41f4bb9b, Sutimlimab-jome (Enjaymo)

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J1302 Sign up free

J1302, Injection, sutimlimab-jome, 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

Documentation of positive clinical response to therapy (e.g., increase in hemoglobin, decreased transfusion requirements, decreased markers of hemolysis, improvement in anemia-related symptoms); and Enjaymo is prescribed by, or in consultation with, a hematologist; and Enjaymo dosing is in accordance with the United States Food and Drug Administration approved labeling; and Patient is not receiving Enjaymo in combination with a complement inhibitor [e.g., eculizumab, Empaveli (pegcetacoplan), Fabhalta (iptacopan), PiaSky (crovalimab), Ultomiris (ravilizumab-cwzb), Zilbrysq (zilucoplan)]; and Reauthorization will be for no more than 12 months
For continuation of therapy, all of the following: o Documentation of positive clinical response to therapy (e.g., increase in hemoglobin, decreased transfusion requirements, decreased markers of hemolysis, improvement in anemia-related symptoms); and o Enjaymo is prescribed by, or in consultation with, a hematologist; and o Enjaymo dosing is in accordance with the United States Food and Drug Administration approved labeling; and o Patient is not receiving Enjaymo in combination with a complement inhibitor [e.g., eculizumab, Empaveli (pegcetacoplan), Fabhalta (iptacopan), PiaSky (crovalimab), Ultomiris (ravilizumab-cwzb), Zilbrysq (zilucoplan)]; and o Reauthorization will be for no more than 12 months
Documentation: prior authorization required by HealthPartners Pharmacy Administration.

Key Coverage Criteria

Adults with CAD may be eligible for sutimlimab-jome (Enjaymo®) when there is chronic hemolysis, positive polyspecific DAT, monospecific DAT for C3d, and cold agglutinin titer ≥64 at 4°C, and the CAD is not secondary to infection, rheumatologic disease, SLE/other autoimmune disorders with ANA, or overt hematologic malignancy.
Enjaymo is indicated for the treatment of hemolysis in adults with cold agglutinin disease (CAD).
Enjaymo is medically necessary for the treatment of CAD in patients who meet all of the following criteria: For initial therapy, all of the following: o Diagnosis of CAD by, or in consultation with, a hematologist with expertise in the diagnosis of CAD; and Confirmation of the CAD diagnosis based on all of the following:  Evidence of chronic hemolysis [e.g., elevated lactated dehydrogenase (LDH), decreased haptoglobin, increased indirect bilirubin, increased ret [...]
Enjaymo is medically necessary for the treatment of CAD in patients who meet all of the following criteria: For initial therapy, all of the following: o Diagnosis of CAD by, or in consultation with, a hematologist with expertise in the diagnosis of CAD; and o Confirmation of the CAD diagnosis based on all of the following:  Evidence of chronic hemolysis [e.g., elevated lactated dehydrogenase (LDH), decreased haptoglobin, increased indirect bilirubin, increased [...]
Indication: confirmed diagnosis of primary cold agglutinin disease.
Indication: patient body weight at least 39 kg prior to initiation of Enjaymo.

20 Active Policies

ARKBLUE-SUTIMLIMAB-JOME-E-G-ENJAYMO-8248891493, Sutimlimab-jome (e.g., Enjaymo)

BCBSLA-00800-FFD08C0D9E, 00800 sutimlimab-jome (Enjaymo)

BCBSM-2159171-4DEE98F9F1, ENJAYMO (SUTIMLIMAB INTRAVENOUS INJECTION)

BCBSMS-S-5-01-585-A717FE249D, State and School Employees' Health Insurance Plan - Enjaymo (sutimlimab-jome)

BCBSMS-L-5-01-585-A99DFB7997, Enjaymo (sutimlimab-jome)

HEALTHPARTNERS-CC-ENTRY-249186, Sutimlimab-jome (Enjaymo)

MULTI

POINT32HEALTH-MDMNG-12751, Enjaymo (sutimlimab-jome)

MULTI

BCBSNE-X-195-122F420D43, ENJAYMO (PREAUTHORIZATION REQUIRED)

MODA-ENJAYMO-44A81E77DB, Enjaymo (sutimlimab-jome)

HEALTHNET_OR-HNOR-SUTIMLIMAB-JOME-ENJAYMO-CP-PHAR-503-D87B78E376, Sutimlimab-jome (Enjaymo); CP.PHAR.503

IBX-COMMERCIAL-08-01-87A-8EE6979156, Sutimlimab-jome (Enjaymo)

IBX-MEDICARE-ADVANTAGE-MA08-145A-647F2940CF, Sutimlimab-jome (Enjaymo)

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

BCBSOK-RX501.180, Sutimlimab-jome

UMR-POL-UMR-enjaymo, Enjaymo (Sutimlimab-Jome)

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

SUREST-POL-SUREST-enjaymo, Enjaymo (Sutimlimab-Jome)

AMERIHEALTH-COMMERCIAL-08-01-87A-60F531FF2A, Sutimlimab-jome (Enjaymo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-145A-F2D90981BC, Sutimlimab-jome (Enjaymo)

BCBSTN-9a41f4bb9b, Sutimlimab-jome (Enjaymo)

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J1302 Sign up free

`J1302`, Injection, sutimlimab-jome, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1302`, Injection, sutimlimab-jome, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1302, Injection, sutimlimab-jome, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1302, Injection, sutimlimab-jome, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1302`, Injection, sutimlimab-jome, 10 mg

`J1302`, Injection, sutimlimab-jome, 10 mg