Does J2353 require prior authorization?

Yes, J2353 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2353?

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

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`J2353`, Injection, octreotide, depot form for intramuscular injection, 1 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.
Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
This Medical Benefit Drug Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan.
Documentation of a prior trial with short-acting subcutaneous octreotide demonstrating clinical effectiveness and tolerability is required before coverage of long-acting octreotide.
For acromegaly, documentation of baseline and post-treatment GH and/or IGF-1 levels consistent with therapeutic goals (reduction toward normal) is expected per FDA treatment intent.

Key Coverage Criteria

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.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
Indication: Acromegaly in patients who have had inadequate response to or cannot be treated with surgical resection, pituitary irradiation, or dopamine agonist at maximally tolerated doses.
Indication: Long-term maintenance therapy in acromegalic patients who have shown response to and can tolerate octreotide acetate injection.

20 Active Policies

ARKBLUE-OCTREOTIDE-ACETATE-E-G-SANDOSTATIN-FOR-INJECTABL-2E9A8D92BF, Octreotide Acetate (e.g., Sandostatin) for Injectable Suspension (e.g., Sandostatin LAR Depot)

PALMETTO-JJ-L33438, Octreotide Acetate for Injectable Suspension (Sandostatin LAR depot)

PALMETTO-JM-L33438, Octreotide Acetate for Injectable Suspension (Sandostatin LAR depot)

BCBSNJ-DRUGS-118-6096E061EB, Sandostatin, Sandostatin LAR depot (Octreotide), Somatuline Depo (lanreotide), Signifor LAR (pasireotide)

HEALTHNET_OR-HNOR-OCTREOTIDE-ACETATE-SANDOSTATIN-SANDOSTATIN-LAR-MYCAPSSA-00E7CF9A18, Octreotide Acetate (Sandostatin, Sandostatin LAR, Mycapssa); CP.PHAR.40

HIGHMARK_WHOLECARE-HMWC-MEDICAID-MEDICATIO-RZEGJIHUBU2HKGDEO5VX1W-AE60B62C50, Sandostatin LAR Depot

IBX-COMMERCIAL-08-01-10L-35F73BF6DD, Octreotide Acetate (Sandostatin LAR Depot)

IBX-MA-PPO-HOST-MA08-065I-899CA07BB8, Octreotide Acetate (Sandostatin LAR Depot)

IBX-MEDICARE-ADVANTAGE-MA08-065L-E51551DDA4, Octreotide Acetate (Sandostatin LAR Depot)

BCBSMT-RX502.061, Oncology Medications

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

BCBSNM-RX501.156, Octreotide

BCBSNM-RX502.061, Oncology Medications

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

BCBSOK-RX501.156, Octreotide

BCBSOK-RX502.061, Oncology Medications

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

UMR-POL-UMR-somatostatin-analogs, Somatostatin Analogs

SUREST-POL-SUREST-somatostatin-analogs, Somatostatin Analogs

AMERIHEALTH-COMMERCIAL-08-01-10L-82CACE8F17, Octreotide Acetate (Sandostatin LAR Depot)

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J2353, Injection, octreotide, depot form for intramuscular injection, 1 mg