Does J2675 require prior authorization?

Yes, J2675 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J2675?

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

Backwork Sign up free

`J2675`, Injection, progesterone, per 50 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For Nexplanon insertion/removal: documentation that insertion and planned removal will follow labeled duration (removed by end of 3rd year) and adherence to label contraindications/warnings.
For intramuscular 17-OHPC regimens: documentation of dosing schedule and gestational age at treatment initiation (policy/guideline references: 250 mg intramuscularly weekly, preferably starting at 16–20 weeks and continuing through 36 weeks).

For contraceptive coverage (Depo-Provera, implants, IUDs): documentation that the member's plan covers contraceptive drugs/devices when required (policy text: Depo-Provera coverage limited to plans that specifically cover contraceptive drugs/devices).

For implants (Implanon/Nexplanon) and IUDs: documentation of informed consent and screening for contraindications (pregnancy test when appropriate; history of breast cancer or other progestin-sensitive cancers; liver disease; undiagnosed abnormal genital bleeding).

For medroxyprogesterone injection use in adolescents or long-term use: documentation of risk/benefit discussion regarding bone mineral density loss and consideration of alternative methods (policy black box warning implications).

For use of progesterone in assisted reproduction/luteal support: documentation of IVF/ET procedure timing if product used as luteal support (policy cites studies of luteal support and IVF).

Key Coverage Criteria

Etonogestrel Subdermal Implant: "Aetna considers etonogestrel subdermal implant (Nexplanon) medically necessary for the prevention of pregnancy."
Medroxyprogesterone Acetate Injection (Depo-Provera CI or generic formulation 150 mg/mL): "Aetna considers Depo-Provera CI or generic formulation 150 mg/mL medically necessary for the following indications: Prevention of pregnancy."
Medroxyprogesterone Acetate Injection for Gender Dysphoria: "Gender dysphoria when all of the following are met: The member is able to make an informed decision to engage in hormone therapy; and The member has a diagnosis of gender dysphoria; and The member's comorbid conditions are reasonably controlled; and The member has been educated on any contraindications and side effects to therapy; and If the member is less than 18 years of age, the requested medication will be prescribed by or in consu [...]
Depo-Provera 400 mg/mL: "Aetna considers Depo-Provera 400 mg/mL medically necessary as adjunctive therapy and palliative treatment of inoperable, recurrent, and metastatic endometrial or renal carcinoma."
Implanon (etonogestrel implant) — single-rod progestogen-only contraceptive implant; long-acting (up to 3 years), reversible contraceptive method.
Levonorgestrel-releasing intrauterine systems (examples: Mirena, Kyleena, Skyla, Liletta) — contraceptive devices indicated for prevention of pregnancy (durations vary by product: Mirena up to 5 years; Skyla up to 3 years; Liletta up to 3 years; Kyleena up to 5 years).

7 Active Policies

BCBSMS-L-2-04-414-CAD0DB5ED1, Progesterone Testing

POINT32HEALTH-PMNG-17556, Progesterone Medications: (progesterone oil injectable; Crinone gel)

MULTI

BCBSNE-X-72-099F811BEA, PROGESTERONE THERAPY AS A TECHNIQUE TO REDUCE PRETERM BIRTH IN HIGH-RISK PREGNANCIES (PREAUTHORIZATION REQUIRED)

BCBSNJ-OBSTETRICS-006-F86C46D1F6, Progesterone Therapy as a Technique to Reduce Preterm Delivery in High Risk Pregnancies

HEALTHNET_OR-HNOR-PROGESTERONE-CRINONE-ENDOMETRIN-CP-PMN-243-BAB057955C, Progesterone (Crinone, Endometrin); CP.PMN.243

BCBSRI-PROGESTERONE-THERAPY-AS-A-TECHNIQUE-TO-REDUCE-PRETERM-BIRTH-046CC15A75, Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies

AETNA-CPB-0510, Progestins

Have a follow-up question?

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

Ask Backwork about J2675 Sign up free

J2675, Injection, progesterone, per 50 mg