Does J1412 require prior authorization?

No, J1412 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J1412?

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

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Prescriber attests that the patient’s ALT and factor VIII activity will be monitored weekly for at least 26 weeks following administration of Roctavian and regularly thereafter per the monitoring schedule recommended in the prescribing information; and
Roctavian dosing is in accordance with the United States Food and Drug Administration approved labeling; and

Roctavian is proven and medically necessary for the treatment of Hemophilia A (factor VIII Deficiency) when all of the following criteria are met: Patient is 18 years of age or older; and Diagnosis of severe hemophilia A; Documentation of endogenous factor VIII levels < 1% of normal; and one of the following: patient on non-factor replacement therapy or on factor VIII prophylaxis with at least 150 exposure days, or appropriate HTC candidate with monitoring adherence and no inhibitors ≥0.6 BU, no [...]
Etranacogene dezaparvovec-drlb is consideredmedically necessaryin individuals who meetallof the following criteria:
Diagnosis of hemophilia B;and
Age 18 years or older;and
Baseline factor IX level is less than 1 international unit (IU)/deciliter (dL) (or 1% endogenous factor IX);and
No contraindications to infusion (if any of the following are present, treatment is contraindicated):Active infection;orImmunosuppressive disorder;orLiver cirrhosis;orActive hepatitis B or C;orAlanine transaminase (ALT) greater than 3 times the upper limit of normal;orBilirubin greater than 3 times the upper limit of normal;orAlkaline phosphatase greater than 3 times the upper limit of normal;orInternational normalized ratio (INR) greater than1.4.;orPrior infusion of gene therapy for hemophilia [...]

ANTHEM-MED.00135, Gene Therapy for Hemophilia

UHC-POL-roctavian, Roctavian (Valoctocogene Roxaparvovec-Rvox)

BCBSIL-RX501.128, Valoctocogene Roxaparvovec-rvox

BCBSMT-RX501.128, Valoctocogene Roxaparvovec-rvox

BCBSNM-RX501.128, Valoctocogene Roxaparvovec-rvox

BCBSOK-RX501.128, Valoctocogene Roxaparvovec-rvox

UMR-POL-UMR-roctavian, Roctavian (Valoctocogene Roxaparvovec-Rvox)

SUREST-POL-SUREST-roctavian, Roctavian (Valoctocogene Roxaparvovec-Rvox)