Does J1746 require prior authorization?

Yes, J1746 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1746?

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

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`J1746`, Injection, ibalizumab-uiyk, 10 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

Provider attestation that the patient has multi-drug resistant HIV-1 infection (required for initial therapy)
Provider confirmation/documentation that the patient has been prescribed an optimized background antiretroviral regimen containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility (required for initial and continuation therapy)
For continuation therapy: documentation that the patient has previously received Trogarzo (ibalizumab-uiyk)
For continuation therapy: provider confirmation/documentation that the patient has achieved a clinically significant viral response to Trogarzo therapy (e.g., documented viral load response)
Documentation that Trogarzo dosing (initial and maintenance) follows the US FDA prescribing information
Member-specific benefit plan document should be consulted (policy states coverage decisions must reference the member specific benefit plan document and applicable laws/mandates)

Key Coverage Criteria

Trogarzo (ibalizumab-uiyk) is proven and medically necessary for the treatment of multi-drug resistant human immunodeficiency virus (HIV) in patients who meet all of the following criteria:
For initial therapy, all of the following:
Diagnosis of HIV-1 infection
Provider attestation that the patient has multi-drug resistant HIV-1 infection
Provider confirms that the patient has been prescribed an optimized background antiretroviral regimen, containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility
Trogarzo (ibalizumab-uiyk) initial and maintenance dosing is in accordance with the US Food and Drug Administration prescribing information

20 Active Policies

BCBSM-2092937-AEDD4D7DB4, TROGARZO (IBALIZUMAB-ULYK)

HEALTHPARTNERS-CC-ENTRY-204624, Ibalizumab-uiyk (Trogarzo) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-ENTRY-202453, Ibalizumab-uiyk (Trogarzo)

MULTI

BCBSND-IBALIZUMAB-UIYK-TROGARZO-68115E7C2D, Ibalizumab Uiyk Trogarzo

BCBSNE-X-113-A935352958, TROGARZO (REQUIRES PREAUTHORIZATION

BCBSNJ-DRUGS-178-1D21FCB9E6, Ibalizumab-uiyk (Trogarzo)

MODA-TROGARZO-0E60A196BF, Trogarzo (ibalizumab-uiyk)

HEALTHNET_OR-HNOR-IBALIZUMAB-UIYK-TROGARZO-CP-PHAR-378-2C2479510F, Ibalizumab-uiyk (Trogarzo); CP. PHAR.378

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

UMR-POL-UMR-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

BCBSTN-1f850629fb, Ibalizumab-uiyk (Trogarzo)

EVICORE-MEDICAL_DRUG-0836DAFBF1ED, Trogarzo (ibalizumab-uiyk injection)

UHC-COMM-MD-TROGARZO-IBALIZUMAB-UIYK-COMMUNITY-PLAN-BF30EB31FC, Trogarzo (Ibalizumab-Uiyk) – Community Plan Medical Benefit Drug Policy

UHC-EXCH-MD-TROGARZO-IBALIZUMAB-UIYK-COMMERCIAL-AND-60F5A6C01F, Trogarzo (Ibalizumab-Uiyk) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

SUREST-POL-SUREST-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

BCBSIL-RX501.099, Ibalizumab-uiyk

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

BCBSMT-RX501.099, Ibalizumab-uiyk

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

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J1746, Injection, ibalizumab-uiyk, 10 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

Provider attestation that the patient has multi-drug resistant HIV-1 infection (required for initial therapy)
Provider confirmation/documentation that the patient has been prescribed an optimized background antiretroviral regimen containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility (required for initial and continuation therapy)
For continuation therapy: documentation that the patient has previously received Trogarzo (ibalizumab-uiyk)
For continuation therapy: provider confirmation/documentation that the patient has achieved a clinically significant viral response to Trogarzo therapy (e.g., documented viral load response)
Documentation that Trogarzo dosing (initial and maintenance) follows the US FDA prescribing information
Member-specific benefit plan document should be consulted (policy states coverage decisions must reference the member specific benefit plan document and applicable laws/mandates)

Key Coverage Criteria

Trogarzo (ibalizumab-uiyk) is proven and medically necessary for the treatment of multi-drug resistant human immunodeficiency virus (HIV) in patients who meet all of the following criteria:
For initial therapy, all of the following:
Diagnosis of HIV-1 infection
Provider attestation that the patient has multi-drug resistant HIV-1 infection
Provider confirms that the patient has been prescribed an optimized background antiretroviral regimen, containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility
Trogarzo (ibalizumab-uiyk) initial and maintenance dosing is in accordance with the US Food and Drug Administration prescribing information

20 Active Policies

BCBSM-2092937-AEDD4D7DB4, TROGARZO (IBALIZUMAB-ULYK)

HEALTHPARTNERS-CC-ENTRY-204624, Ibalizumab-uiyk (Trogarzo) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-ENTRY-202453, Ibalizumab-uiyk (Trogarzo)

MULTI

BCBSND-IBALIZUMAB-UIYK-TROGARZO-68115E7C2D, Ibalizumab Uiyk Trogarzo

BCBSNE-X-113-A935352958, TROGARZO (REQUIRES PREAUTHORIZATION

BCBSNJ-DRUGS-178-1D21FCB9E6, Ibalizumab-uiyk (Trogarzo)

MODA-TROGARZO-0E60A196BF, Trogarzo (ibalizumab-uiyk)

HEALTHNET_OR-HNOR-IBALIZUMAB-UIYK-TROGARZO-CP-PHAR-378-2C2479510F, Ibalizumab-uiyk (Trogarzo); CP. PHAR.378

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

UMR-POL-UMR-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

BCBSTN-1f850629fb, Ibalizumab-uiyk (Trogarzo)

EVICORE-MEDICAL_DRUG-0836DAFBF1ED, Trogarzo (ibalizumab-uiyk injection)

UHC-COMM-MD-TROGARZO-IBALIZUMAB-UIYK-COMMUNITY-PLAN-BF30EB31FC, Trogarzo (Ibalizumab-Uiyk) – Community Plan Medical Benefit Drug Policy

UHC-EXCH-MD-TROGARZO-IBALIZUMAB-UIYK-COMMERCIAL-AND-60F5A6C01F, Trogarzo (Ibalizumab-Uiyk) – Commercial and Individual Exchange Medical Benefit Drug Policy

UHC-POL-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

SUREST-POL-SUREST-trogarzo-ibalizumab-uiyk, Trogarzo (Ibalizumab-Uiyk)

BCBSIL-RX501.099, Ibalizumab-uiyk

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

BCBSMT-RX501.099, Ibalizumab-uiyk

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

Have a follow-up question?

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

Ask Backwork about J1746 Sign up free

`J1746`, Injection, ibalizumab-uiyk, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1746`, Injection, ibalizumab-uiyk, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1746, Injection, ibalizumab-uiyk, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1746, Injection, ibalizumab-uiyk, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1746`, Injection, ibalizumab-uiyk, 10 mg

`J1746`, Injection, ibalizumab-uiyk, 10 mg