Does J1305 require prior authorization?

Yes, J1305 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1305?

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

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`J1305`, Injection, evinacumab-dgnb, 5mg

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

Diagnosis of HoFH by, or in consultation with, a lipid specialist (e.g., cardiologist, endocrinologist, lipid specialist/lipidologist) experienced in the management of HoFH.
Submission of medical records (e.g., chart notes, laboratory values) confirming genetic confirmation of biallelic pathogenic/likely pathogenic variants on different chromosomes at the LDLR, APOB, PCSK9, or LDLRAP1 genes or ≥ 2 such variants at different loci; OR documentation of BOTH: untreated LDL-C > 400 mg/dL AND one of: xanthoma before 10 years of age; OR evidence of familial hypercholesterolemia in at least one parent.
If using the LDL-C / clinical criteria pathway: laboratory documentation of untreated LDL-C > 400 mg/dL and clinical documentation of xanthoma before age 10 and/or family history consistent with FH in a parent, as described above.
Documentation of current lipid-lowering therapies and plan to continue other traditional LDL-C lowering therapies (e.g., maximally tolerated statins, ezetimibe) in combination with Evkeeza.
Documentation of prior/current statin therapy or documentation of statin intolerance/contraindication. Statin intolerance evidence may include: intolerable and persistent (>2 weeks) muscle symptoms (myalgia) without CK elevations; myositis with CK elevations <10x ULN; rhabdomyolysis or CK elevations >10x ULN; or contraindication to all statins.
Documentation of receipt of ezetimibe as adjunct to maximally tolerated statin therapy or documentation of ezetimibe intolerance/contraindication.

Key Coverage Criteria

Evkeeza (evinacumab-dgnb) is proven and medically necessary for the treatment of homozygous familial hypercholesterolemia (HoFH) patients who meet all of the following criteria:
For initial therapy, all of the following: Diagnosis of HoFH by, or in consultation with, a lipid specialist (e.g., cardiologist, endocrinologist, lipid specialist/lipidologist); and Confirmation of the HoFH diagnosis based on one of the following: (a) Submission of medical records (e.g., chart notes, laboratory values) confirming genetic confirmation of biallelic pathogenic/likely pathogenic variants on different chromosomes at the low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB [...]
For continuation of therapy, all of the following: Documentation of a positive clinical response to Evkeeza therapy; and Evkeeza will not be used in combination with Juxtapid (lomitapide); and Evkeeza dosing is in accordance with the United States Food and Drug Administration approved labeling; and reauthorization will be for no more than 12 months.
FDA indication (informational): Evkeeza is indicated as an adjunct to other low-density lipoprotein-cholesterol (LDL-C) lowering therapies for the treatment of adult and pediatric patients, aged 5 years and older, with homozygous familial hypercholesterolemia (HoFH).
FDA-approved: Evkeeza as an adjunct to diet and exercise and other low-density lipoprotein cholesterol (LDL-C) lowering therapies to reduce LDL-C in adults and pediatric patients aged ≥1 year with homozygous familial hypercholesterolemia (HoFH).
HoFH with diagnosis confirmed by genetic testing (e.g., pathogenic variants at LDLR, APOB, PCSK9, or LDLRAP1 loci).

20 Active Policies

ARKBLUE-EVINACUMAB-DGNB-E-G-EVKEEZA-F3798B2218, Evinacumab-dgnb (e.g., Evkeeza)

BCBSLA-00751-3E37F41555, 00751 evinacumab-dgnb (Evkeeza)

BCBSM-2145517-E70547921F, EVKEEZA (EVINACUMAB)

POINT32HEALTH-MDMNG-12831, Evkeeza (evinacumab-dgnb)

MULTI

HEALTHPARTNERS-CC-ENTRY-234244, Evinacumab-dgnb (Evkeeza)

MULTI

BCBSND-EVINACUMAB-DGNB-EVKEEZA-9C286512CA, Evinacumab Dgnb Evkeeza

BCBSNE-X-168-B6B0B1B388, EVKEEZA (EVINACUMAB) (REQUIRES PRIOR AUTHORIZATION)

MODA-EVKEEZA-ED3F998B66, Evkeeza (evinacumab-dgnb)

HEALTHNET_OR-HNOR-EVINACUMAB-DGNB-EVKEEZA-CP-PHAR-511-CAA0481FDB, Evinacumab-dgnb (Evkeeza); CP.PHAR.511

IBX-MEDICARE-ADVANTAGE-MA08-133D-1009F53018, Evinacumab-dgnb (Evkeeza)

IBX-COMMERCIAL-08-01-76D-5BF4229D7A, Evinacumab-dgnb (Evkeeza)

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

SUREST-POL-SUREST-evkeeza, Evkeeza (Evinacumab-Dgnb)

AMERIHEALTH-COMMERCIAL-08-01-76D-449D5F0977, Evinacumab-dgnb (Evkeeza)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-133D-6E6C0370B7, Evinacumab-dgnb (Evkeeza)

BCBSTN-a0f9adea54, Evinacumab-dgnb (Evkeeza)

EVICORE-MEDICAL_DRUG-04890B36CCC9, Evkeeza (evinacumab-dgnb)Effective 09/01/2026

EVICORE-MEDICAL_DRUG-1B1E87BA265E, Evkeeza (evinacumab-dgnb)

UHC-COMM-MD-EVKEEZA-EVINACUMAB-DGNB-COMMUNITY-PLAN-M-D93F186FE2, Evkeeza (Evinacumab-Dgnb) – Community Plan Medical Benefit Drug Policy

UHC-POL-evkeeza, Evkeeza (Evinacumab-Dgnb)

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

Ask Backwork about J1305 Sign up free

J1305, Injection, evinacumab-dgnb, 5mg

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

Diagnosis of HoFH by, or in consultation with, a lipid specialist (e.g., cardiologist, endocrinologist, lipid specialist/lipidologist) experienced in the management of HoFH.
Submission of medical records (e.g., chart notes, laboratory values) confirming genetic confirmation of biallelic pathogenic/likely pathogenic variants on different chromosomes at the LDLR, APOB, PCSK9, or LDLRAP1 genes or ≥ 2 such variants at different loci; OR documentation of BOTH: untreated LDL-C > 400 mg/dL AND one of: xanthoma before 10 years of age; OR evidence of familial hypercholesterolemia in at least one parent.
If using the LDL-C / clinical criteria pathway: laboratory documentation of untreated LDL-C > 400 mg/dL and clinical documentation of xanthoma before age 10 and/or family history consistent with FH in a parent, as described above.
Documentation of current lipid-lowering therapies and plan to continue other traditional LDL-C lowering therapies (e.g., maximally tolerated statins, ezetimibe) in combination with Evkeeza.
Documentation of prior/current statin therapy or documentation of statin intolerance/contraindication. Statin intolerance evidence may include: intolerable and persistent (>2 weeks) muscle symptoms (myalgia) without CK elevations; myositis with CK elevations <10x ULN; rhabdomyolysis or CK elevations >10x ULN; or contraindication to all statins.
Documentation of receipt of ezetimibe as adjunct to maximally tolerated statin therapy or documentation of ezetimibe intolerance/contraindication.

Key Coverage Criteria

Evkeeza (evinacumab-dgnb) is proven and medically necessary for the treatment of homozygous familial hypercholesterolemia (HoFH) patients who meet all of the following criteria:
For initial therapy, all of the following: Diagnosis of HoFH by, or in consultation with, a lipid specialist (e.g., cardiologist, endocrinologist, lipid specialist/lipidologist); and Confirmation of the HoFH diagnosis based on one of the following: (a) Submission of medical records (e.g., chart notes, laboratory values) confirming genetic confirmation of biallelic pathogenic/likely pathogenic variants on different chromosomes at the low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB [...]
For continuation of therapy, all of the following: Documentation of a positive clinical response to Evkeeza therapy; and Evkeeza will not be used in combination with Juxtapid (lomitapide); and Evkeeza dosing is in accordance with the United States Food and Drug Administration approved labeling; and reauthorization will be for no more than 12 months.
FDA indication (informational): Evkeeza is indicated as an adjunct to other low-density lipoprotein-cholesterol (LDL-C) lowering therapies for the treatment of adult and pediatric patients, aged 5 years and older, with homozygous familial hypercholesterolemia (HoFH).
FDA-approved: Evkeeza as an adjunct to diet and exercise and other low-density lipoprotein cholesterol (LDL-C) lowering therapies to reduce LDL-C in adults and pediatric patients aged ≥1 year with homozygous familial hypercholesterolemia (HoFH).
HoFH with diagnosis confirmed by genetic testing (e.g., pathogenic variants at LDLR, APOB, PCSK9, or LDLRAP1 loci).

20 Active Policies

ARKBLUE-EVINACUMAB-DGNB-E-G-EVKEEZA-F3798B2218, Evinacumab-dgnb (e.g., Evkeeza)

BCBSLA-00751-3E37F41555, 00751 evinacumab-dgnb (Evkeeza)

BCBSM-2145517-E70547921F, EVKEEZA (EVINACUMAB)

POINT32HEALTH-MDMNG-12831, Evkeeza (evinacumab-dgnb)

MULTI

HEALTHPARTNERS-CC-ENTRY-234244, Evinacumab-dgnb (Evkeeza)

MULTI

BCBSND-EVINACUMAB-DGNB-EVKEEZA-9C286512CA, Evinacumab Dgnb Evkeeza

BCBSNE-X-168-B6B0B1B388, EVKEEZA (EVINACUMAB) (REQUIRES PRIOR AUTHORIZATION)

MODA-EVKEEZA-ED3F998B66, Evkeeza (evinacumab-dgnb)

HEALTHNET_OR-HNOR-EVINACUMAB-DGNB-EVKEEZA-CP-PHAR-511-CAA0481FDB, Evinacumab-dgnb (Evkeeza); CP.PHAR.511

IBX-MEDICARE-ADVANTAGE-MA08-133D-1009F53018, Evinacumab-dgnb (Evkeeza)

IBX-COMMERCIAL-08-01-76D-5BF4229D7A, Evinacumab-dgnb (Evkeeza)

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

SUREST-POL-SUREST-evkeeza, Evkeeza (Evinacumab-Dgnb)

AMERIHEALTH-COMMERCIAL-08-01-76D-449D5F0977, Evinacumab-dgnb (Evkeeza)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-133D-6E6C0370B7, Evinacumab-dgnb (Evkeeza)

BCBSTN-a0f9adea54, Evinacumab-dgnb (Evkeeza)

EVICORE-MEDICAL_DRUG-04890B36CCC9, Evkeeza (evinacumab-dgnb)Effective 09/01/2026

EVICORE-MEDICAL_DRUG-1B1E87BA265E, Evkeeza (evinacumab-dgnb)

UHC-COMM-MD-EVKEEZA-EVINACUMAB-DGNB-COMMUNITY-PLAN-M-D93F186FE2, Evkeeza (Evinacumab-Dgnb) – Community Plan Medical Benefit Drug Policy

UHC-POL-evkeeza, Evkeeza (Evinacumab-Dgnb)

Have a follow-up question?

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

Ask Backwork about J1305 Sign up free

`J1305`, Injection, evinacumab-dgnb, 5mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1305`, Injection, evinacumab-dgnb, 5mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1305, Injection, evinacumab-dgnb, 5mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1305, Injection, evinacumab-dgnb, 5mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1305`, Injection, evinacumab-dgnb, 5mg

`J1305`, Injection, evinacumab-dgnb, 5mg