Does J2507 require prior authorization?

Yes, J2507 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2507?

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

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`J2507`, Injection, pegloticase, 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

Documentation: Enrollment in REMS safety program may be required, with possible prescriber/facility certification.
Initial: Prior authorization validity will be provided initially for 6 months; Renewal: Prior authorization validity may be renewed annually thereafter.

Key Coverage Criteria

Pegloticase is medically necessary for adults (≥18) with chronic gout who are refractory to conventional therapies, defined by SUA ≥6 mg/dL, symptomatic gout with ≥2 flares in the prior year or ≥1 tophus/gouty arthritis, and history of contraindication, intolerance, or failure to normalize uric acid (<6 mg/dL) on conventional therapy.
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: Adult patients (age ≥18) with severe symptomatic gout who are treated under rheumatology or nephrology oversight, fulfilling additional criteria A-D as specified. Requires ongoing monitoring and prior documentation of uric acid and treatment history per criteria A-D.
Indication: Recent uric acid >6 mg/dL within 1 month plus history of multiple gout events or CKD due to uric acid nephropathy, and failed trials of allopurinol, probenecid, and febuxostat (3-month trials each, adherence >80%/year).
Indication: Uric acid monitoring before each infusion with consideration to discontinue if preinfusion uric acid >6 mg/dL (note higher anaphylaxis risk with >6 mg/dL, esp. two consecutive readings).

20 Active Policies

ARKBLUE-PEGLOTICASE-E-G-KRYSTEXXA-F40C1D7D8D, Pegloticase (e.g., Krystexxa)

FLORIDA_BLUE-FLBLUE-PEGLOTICASE-KRYSTEXXA-402B447DCB, Pegloticase (Krystexxa)

BCIDAHO-05-01-665-43DEAED803, Krystexxa. Medical Policy 5.01.665 Krystexxa DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general guidance for applying Blue Cross of Idaho benefit plans (for purposes of this

BCBSLA-00290-51E008DD6B, 00290 pegloticase (Krystexxa)

BCBSM-2036643-E3492DD39B, KRYSTEXXA (PEGLOTICASE)

BCBSMS-S-5-01-462-075BEBD7DF, State and School Employees' Health Insurance Plan - Krystexxa (pegloticase)

BCBSMS-L-5-01-462-98D60B8FD8, Krystexxa (pegloticase)

POINT32HEALTH-MDMNG-13071, Krystexxa (pegloticase)

MULTI

HEALTHPARTNERS-CC-AENTRY-046270, Pegloticase (Krystexxa)

MULTI

BCBSND-PEGLOTICASE-KRYSTEXXA-5D4095AC33, Pegloticase Krystexxa

BCBSNE-X-34-F7E19E4D4A, KRYSTEXXA/ PEGLOTICASE

BCBSNJ-DRUGS-084-9906016B3D, Pegloticase (Krystexxa)

MODA-KRYSTEXKYPROLISXA-5E44E9DF98, Krystexxa (pegloticase)

HEALTHNET_OR-HNOR-PEGLOTICASE-KRYSTEXXA-CP-PHAR-115-8246746B6D, Pegloticase (Krystexxa); CP.PHAR.115

IBX-MEDICARE-ADVANTAGE-MA08-060G-9ED8842090, Pegloticase (Krystexxa)

IBX-COMMERCIAL-08-01-02H-BE61DFF843, Pegloticase (Krystexxa)

UHC-POL-krystexxa-pegloticase, Krystexxa (Pegloticase)

UHC-EXCH-MD-KRYSTEXXA-PEGLOTICASE-INDIVIDUAL-EXCHANG-BFB341F7FC, Krystexxa (Pegloticase) – Individual Exchange Medical Benefit Drug Policy

BCBSIL-RX501.120, Pegloticase

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

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J2507, Injection, pegloticase, 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

Documentation: Enrollment in REMS safety program may be required, with possible prescriber/facility certification.
Initial: Prior authorization validity will be provided initially for 6 months; Renewal: Prior authorization validity may be renewed annually thereafter.

Key Coverage Criteria

Pegloticase is medically necessary for adults (≥18) with chronic gout who are refractory to conventional therapies, defined by SUA ≥6 mg/dL, symptomatic gout with ≥2 flares in the prior year or ≥1 tophus/gouty arthritis, and history of contraindication, intolerance, or failure to normalize uric acid (<6 mg/dL) on conventional therapy.
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: Adult patients (age ≥18) with severe symptomatic gout who are treated under rheumatology or nephrology oversight, fulfilling additional criteria A-D as specified. Requires ongoing monitoring and prior documentation of uric acid and treatment history per criteria A-D.
Indication: Recent uric acid >6 mg/dL within 1 month plus history of multiple gout events or CKD due to uric acid nephropathy, and failed trials of allopurinol, probenecid, and febuxostat (3-month trials each, adherence >80%/year).
Indication: Uric acid monitoring before each infusion with consideration to discontinue if preinfusion uric acid >6 mg/dL (note higher anaphylaxis risk with >6 mg/dL, esp. two consecutive readings).

20 Active Policies

ARKBLUE-PEGLOTICASE-E-G-KRYSTEXXA-F40C1D7D8D, Pegloticase (e.g., Krystexxa)

FLORIDA_BLUE-FLBLUE-PEGLOTICASE-KRYSTEXXA-402B447DCB, Pegloticase (Krystexxa)

BCBSLA-00290-51E008DD6B, 00290 pegloticase (Krystexxa)

BCBSM-2036643-E3492DD39B, KRYSTEXXA (PEGLOTICASE)

BCBSMS-S-5-01-462-075BEBD7DF, State and School Employees' Health Insurance Plan - Krystexxa (pegloticase)

BCBSMS-L-5-01-462-98D60B8FD8, Krystexxa (pegloticase)

POINT32HEALTH-MDMNG-13071, Krystexxa (pegloticase)

MULTI

HEALTHPARTNERS-CC-AENTRY-046270, Pegloticase (Krystexxa)

MULTI

BCBSND-PEGLOTICASE-KRYSTEXXA-5D4095AC33, Pegloticase Krystexxa

BCBSNE-X-34-F7E19E4D4A, KRYSTEXXA/ PEGLOTICASE

BCBSNJ-DRUGS-084-9906016B3D, Pegloticase (Krystexxa)

MODA-KRYSTEXKYPROLISXA-5E44E9DF98, Krystexxa (pegloticase)

HEALTHNET_OR-HNOR-PEGLOTICASE-KRYSTEXXA-CP-PHAR-115-8246746B6D, Pegloticase (Krystexxa); CP.PHAR.115

IBX-MEDICARE-ADVANTAGE-MA08-060G-9ED8842090, Pegloticase (Krystexxa)

IBX-COMMERCIAL-08-01-02H-BE61DFF843, Pegloticase (Krystexxa)

UHC-POL-krystexxa-pegloticase, Krystexxa (Pegloticase)

UHC-EXCH-MD-KRYSTEXXA-PEGLOTICASE-INDIVIDUAL-EXCHANG-BFB341F7FC, Krystexxa (Pegloticase) – Individual Exchange Medical Benefit Drug Policy

BCBSIL-RX501.120, Pegloticase

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

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

Ask Backwork about J2507 Sign up free

`J2507`, Injection, pegloticase, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J2507`, Injection, pegloticase, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J2507, Injection, pegloticase, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J2507, Injection, pegloticase, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J2507`, Injection, pegloticase, 1 mg

`J2507`, Injection, pegloticase, 1 mg