Does J3111 require prior authorization?

Yes, J3111 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J3111?

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

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`J3111`, Injection, romosozumab-aqqg, 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

Prior authorization required from HealthPartners Pharmacy Administration.

Key Coverage Criteria

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).
Postmenopausal osteoporosis with specific bone density/ fracture criteria: (A) BMD score ≤ -2.5 at total hip or femoral neck and at least one vertebral fracture; or (B) BMD score ≤ -2.0 at total hip or femoral neck and at least two vertebral fractures; or (C) proximal femur fracture in the past 24 months.

20 Active Policies

ARKBLUE-ROMOSOZUMAB-AQQG-E-G-EVENITY-41E3A82D18, Romosozumab-aqqg (e.g., Evenity)

FLORIDA_BLUE-FLBLUE-EVENITY-ROMOSOZUMAB-AQQG-3CD89FBDFE, Evenity (romosozumab-aqqg)

BCIDAHO-05-01-675-80479CF2F8, Evenity (romosozumab-aqqg). Medical Policy MP 5.01.675 Evenity (romosozumab-aqqg) DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general guidance for applying Blue Cross of Idaho

BCBSLA-00686-E9EB85DA8F, 00686 romosozumab aqqg (Evenity)

BCBSM-2110214-8F5DE61D0A, EVENITY (ROMOSOZUMAB)

BCBSMS-S-5-01-557-A9196004B7, State and School Employees' Health Insurance Plan - Evenity (romosozumab-aqqg)

BCBSMS-L-5-01-557-2A6F6ECCE9, Evenity (romosozumab-aqqg)

POINT32HEALTH-MDMNG-12811, Evenity (romosozumab-aqqg)

MULTI

HEALTHPARTNERS-CC-ENTRY-212858, Romosozumab-aqqg (Evenity)

MULTI

POINT32HEALTH-MDMNG-12821, Evenity (romosozumab-aqqg)

MULTI

BCBSND-ROMOSOZUMAB-AQQG-EVENITY-C30BFD528C, Romosozumab Aqqg Evenity

BCBSNE-X-136-42C52E6A0F, EVENITY (REQUIRES PRIOR AUTHORIZATION)

BCBSNJ-DRUGS-194-A870D79393, Romosozumab-aqqg (Evenity)

MODA-EVENITY-763841F515, Evenity (romosozumab-aqqg)

HEALTHNET_OR-HNOR-ROMOSOZUMAB-AQQG-EVENITY-CP-PHAR-428-D39FBAE493, Romosozumab-aqqg (Evenity); CP.PHAR.428

IBX-MEDICARE-ADVANTAGE-MA08-052Q-6642B9F176, Denosumab (Prolia, Xgeva) and related biosimilars, and Romosozumab-aqqg (Evenity)

IBX-COMMERCIAL-08-00-94W-5FFCA10AFE, Denosumab (Prolia, Xgeva) and related biosimilars, and Romosozumab-aqqg (Evenity)

UHC-EXCH-MD-EVENITY-ROMOSOZUMAB-AQQG-INDIVIDUAL-EXCH-C8BB84D025, Evenity (Romosozumab-Aqqg) – Individual Exchange Medical Benefit Drug Policy

BCBSIL-RX501.159, Romosozumab-aqqg

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

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J3111, Injection, romosozumab-aqqg, 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

Prior authorization required from HealthPartners Pharmacy Administration.

Key Coverage Criteria

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).
Postmenopausal osteoporosis with specific bone density/ fracture criteria: (A) BMD score ≤ -2.5 at total hip or femoral neck and at least one vertebral fracture; or (B) BMD score ≤ -2.0 at total hip or femoral neck and at least two vertebral fractures; or (C) proximal femur fracture in the past 24 months.

20 Active Policies

ARKBLUE-ROMOSOZUMAB-AQQG-E-G-EVENITY-41E3A82D18, Romosozumab-aqqg (e.g., Evenity)

FLORIDA_BLUE-FLBLUE-EVENITY-ROMOSOZUMAB-AQQG-3CD89FBDFE, Evenity (romosozumab-aqqg)

BCBSLA-00686-E9EB85DA8F, 00686 romosozumab aqqg (Evenity)

BCBSM-2110214-8F5DE61D0A, EVENITY (ROMOSOZUMAB)

BCBSMS-S-5-01-557-A9196004B7, State and School Employees' Health Insurance Plan - Evenity (romosozumab-aqqg)

BCBSMS-L-5-01-557-2A6F6ECCE9, Evenity (romosozumab-aqqg)

POINT32HEALTH-MDMNG-12811, Evenity (romosozumab-aqqg)

MULTI

HEALTHPARTNERS-CC-ENTRY-212858, Romosozumab-aqqg (Evenity)

MULTI

POINT32HEALTH-MDMNG-12821, Evenity (romosozumab-aqqg)

MULTI

BCBSND-ROMOSOZUMAB-AQQG-EVENITY-C30BFD528C, Romosozumab Aqqg Evenity

BCBSNE-X-136-42C52E6A0F, EVENITY (REQUIRES PRIOR AUTHORIZATION)

BCBSNJ-DRUGS-194-A870D79393, Romosozumab-aqqg (Evenity)

MODA-EVENITY-763841F515, Evenity (romosozumab-aqqg)

HEALTHNET_OR-HNOR-ROMOSOZUMAB-AQQG-EVENITY-CP-PHAR-428-D39FBAE493, Romosozumab-aqqg (Evenity); CP.PHAR.428

IBX-MEDICARE-ADVANTAGE-MA08-052Q-6642B9F176, Denosumab (Prolia, Xgeva) and related biosimilars, and Romosozumab-aqqg (Evenity)

IBX-COMMERCIAL-08-00-94W-5FFCA10AFE, Denosumab (Prolia, Xgeva) and related biosimilars, and Romosozumab-aqqg (Evenity)

UHC-EXCH-MD-EVENITY-ROMOSOZUMAB-AQQG-INDIVIDUAL-EXCH-C8BB84D025, Evenity (Romosozumab-Aqqg) – Individual Exchange Medical Benefit Drug Policy

BCBSIL-RX501.159, Romosozumab-aqqg

BCBSIL-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 J3111 Sign up free

`J3111`, Injection, romosozumab-aqqg, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3111`, Injection, romosozumab-aqqg, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3111, Injection, romosozumab-aqqg, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3111, Injection, romosozumab-aqqg, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3111`, Injection, romosozumab-aqqg, 1 mg

`J3111`, Injection, romosozumab-aqqg, 1 mg