Does J3380 require prior authorization?

Yes, J3380 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J3380?

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

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`J3380`, Injection, vedolizumab, intravenous, 1 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

Documentation of diagnosis: moderately to severely active Crohn's disease or moderately to severely active ulcerative colitis (as applicable).
Documentation of one of the following prior to initial therapy for CD/UC: failure, contraindication, or intolerance to at least one conventional therapy (examples: TNF blocker such as adalimumab or certolizumab; immunomodulator such as azathioprine or 6-mercaptopurine; corticosteroid; or corticosteroid dependence).
Documentation that Entyvio is initiated and titrated according to US FDA labeled dosing for the specific indication (Crohn's disease or ulcerative colitis).
Documentation that the patient is not receiving Entyvio in combination with disallowed targeted immunomodulators (examples provided in policy) or natalizumab (Tysabri).
For continuation/re-authorization: documentation of positive clinical response to Entyvio.
For immune checkpoint inhibitor-related toxicities: documentation of receipt of a checkpoint inhibitor (e.g., pembrolizumab, nivolumab), and documentation of one of the specified immunotherapy-related diagnoses (moderate-severe esophagitis/gastritis/duodenitis unresponsive to corticosteroids or budesonide; mild (G1) diarrhea/colitis that is persistent/progressive with positive lactoferrin/calprotectin; or moderate (G2) or severe (G3-4) diarrhea/colitis).

Key Coverage Criteria

Crohn's disease when all of the following criteria are met:
For initial therapy, all of the following:
Diagnosis of moderately to severely active Crohn's disease (CD); and
One of the following: History of failure, contraindication, or intolerance to at least one of the following conventional therapies: Tumor necrosis factor (TNF) blocker [e.g., adalimumab, Cimzia (certolizumab)] Immunomodulator (e.g., azathioprine, 6-mercaptopurine) Corticosteroid Corticosteroid dependent (e.g., unable to successfully taper corticosteroids without a return of the symptoms of CD); and
Entyvio is initiated and titrated according to US Food and Drug Administration (FDA) labeled dosing for Crohn's disease; and
Patient is not receiving Entyvio in combination with either of the following: Targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Omvoh (mirikizumab-mrkz), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), Tremfya (guselkumab), ustekinumab, Xeljanz (tofacitinib)] Tysabri (natalizumab)

20 Active Policies

ARKBLUE-VEDOLIZUMAB-E-G-ENTYVIO-FOR-INFLAMMATORY-BOWEL-D-B39D968A1D, Vedolizumab (e.g., Entyvio) for Inflammatory Bowel Disease

FLORIDA_BLUE-FLBLUE-VEDOLIZUMAB-ENTYVIOTM-4F7FD70B7F, Vedolizumab (Entyvio)

BCIDAHO-05-01-662-39A3C47F51, Entyvio (vedolizumab) for Inflammatory Bowel Disease. Medical Policy MP 5.01.662 Entyvio (vedolizumab) for Inflammatory Bowel Disease DISCLAIMER/INSTRUCTIONS FOR USE This medical policy

BCIDAHO-05-01-662-CAC5D15BB8, Entyvio (vedolizumab) for Inflammatory Bowel Disease. Medical Policy MP 5.01.662 Entyvio (vedolizumab) for Inflammatory Bowel Disease DISCLAIMER/INSTRUCTIONS FOR USE This medical policy

BCBSLA-00439-C149E4E3B7, 00439 vedolizumab (Entyvio)

BCBSMA-162-9DD9E63777, Entyvio (Vedolizumab) Policy

BCBSM-2181826-43A167DE83, ENTYVIO (VEDOLIZUMAB)

POINT32HEALTH-PMNG-24536, Entyvio Subcutaneous Products

MULTI

BCBSND-VEDOLIZUMAB-ENTYVIO-8D7B8CA2ED, Vedolizumab Entyvio

BCBSNJ-DRUGS-121-DECB2B279B, Vedolizumab (Entyvio)

MODA-VEDOLIZUMAB-BB40F994B8, Entyvio (vedolizumab)

IBX-MEDICARE-ADVANTAGE-MA08-001H-0FBDE4CFB4, Vedolizumab (Entyvio) for Injection for Intravenous Use

IBX-COMMERCIAL-08-01-18I-ED892AE49C, Vedolizumab (Entyvio) for Injection for Intravenous Use

SUREST-POL-SUREST-entyvio-vedolizumab, Entyvio (Vedolizumab)

AMERIHEALTH-COMMERCIAL-08-01-18I-9C74E2322B, Vedolizumab (Entyvio) for Injection for Intravenous Use

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-001H-D76853AFFF, Vedolizumab (Entyvio) for Injection for Intravenous Use

BCBSTN-8899b23b4f, Vedolizumab (Entyvio)

EVICORE-MEDICAL_DRUG-08D26F25D2A0, Entyvio Intravenous (vedolizumab)

UHC-COMM-MD-ENTYVIO-VEDOLIZUMAB-COMMUNITY-PLAN-MEDIC-7796F1E8BB, Entyvio (Vedolizumab) – Community Plan Medical Benefit Drug Policy

UHC-POL-entyvio-vedolizumab, Entyvio (Vedolizumab)

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

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J3380, Injection, vedolizumab, intravenous, 1 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

Documentation of diagnosis: moderately to severely active Crohn's disease or moderately to severely active ulcerative colitis (as applicable).
Documentation of one of the following prior to initial therapy for CD/UC: failure, contraindication, or intolerance to at least one conventional therapy (examples: TNF blocker such as adalimumab or certolizumab; immunomodulator such as azathioprine or 6-mercaptopurine; corticosteroid; or corticosteroid dependence).
Documentation that Entyvio is initiated and titrated according to US FDA labeled dosing for the specific indication (Crohn's disease or ulcerative colitis).
Documentation that the patient is not receiving Entyvio in combination with disallowed targeted immunomodulators (examples provided in policy) or natalizumab (Tysabri).
For continuation/re-authorization: documentation of positive clinical response to Entyvio.
For immune checkpoint inhibitor-related toxicities: documentation of receipt of a checkpoint inhibitor (e.g., pembrolizumab, nivolumab), and documentation of one of the specified immunotherapy-related diagnoses (moderate-severe esophagitis/gastritis/duodenitis unresponsive to corticosteroids or budesonide; mild (G1) diarrhea/colitis that is persistent/progressive with positive lactoferrin/calprotectin; or moderate (G2) or severe (G3-4) diarrhea/colitis).

Key Coverage Criteria

Crohn's disease when all of the following criteria are met:
For initial therapy, all of the following:
Diagnosis of moderately to severely active Crohn's disease (CD); and
One of the following: History of failure, contraindication, or intolerance to at least one of the following conventional therapies: Tumor necrosis factor (TNF) blocker [e.g., adalimumab, Cimzia (certolizumab)] Immunomodulator (e.g., azathioprine, 6-mercaptopurine) Corticosteroid Corticosteroid dependent (e.g., unable to successfully taper corticosteroids without a return of the symptoms of CD); and
Entyvio is initiated and titrated according to US Food and Drug Administration (FDA) labeled dosing for Crohn's disease; and
Patient is not receiving Entyvio in combination with either of the following: Targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Omvoh (mirikizumab-mrkz), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), Tremfya (guselkumab), ustekinumab, Xeljanz (tofacitinib)] Tysabri (natalizumab)

20 Active Policies

ARKBLUE-VEDOLIZUMAB-E-G-ENTYVIO-FOR-INFLAMMATORY-BOWEL-D-B39D968A1D, Vedolizumab (e.g., Entyvio) for Inflammatory Bowel Disease

FLORIDA_BLUE-FLBLUE-VEDOLIZUMAB-ENTYVIOTM-4F7FD70B7F, Vedolizumab (Entyvio)

BCBSLA-00439-C149E4E3B7, 00439 vedolizumab (Entyvio)

BCBSMA-162-9DD9E63777, Entyvio (Vedolizumab) Policy

BCBSM-2181826-43A167DE83, ENTYVIO (VEDOLIZUMAB)

POINT32HEALTH-PMNG-24536, Entyvio Subcutaneous Products

MULTI

BCBSND-VEDOLIZUMAB-ENTYVIO-8D7B8CA2ED, Vedolizumab Entyvio

BCBSNJ-DRUGS-121-DECB2B279B, Vedolizumab (Entyvio)

MODA-VEDOLIZUMAB-BB40F994B8, Entyvio (vedolizumab)

IBX-MEDICARE-ADVANTAGE-MA08-001H-0FBDE4CFB4, Vedolizumab (Entyvio) for Injection for Intravenous Use

IBX-COMMERCIAL-08-01-18I-ED892AE49C, Vedolizumab (Entyvio) for Injection for Intravenous Use

SUREST-POL-SUREST-entyvio-vedolizumab, Entyvio (Vedolizumab)

AMERIHEALTH-COMMERCIAL-08-01-18I-9C74E2322B, Vedolizumab (Entyvio) for Injection for Intravenous Use

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-001H-D76853AFFF, Vedolizumab (Entyvio) for Injection for Intravenous Use

BCBSTN-8899b23b4f, Vedolizumab (Entyvio)

EVICORE-MEDICAL_DRUG-08D26F25D2A0, Entyvio Intravenous (vedolizumab)

UHC-COMM-MD-ENTYVIO-VEDOLIZUMAB-COMMUNITY-PLAN-MEDIC-7796F1E8BB, Entyvio (Vedolizumab) – Community Plan Medical Benefit Drug Policy

UHC-POL-entyvio-vedolizumab, Entyvio (Vedolizumab)

Have a follow-up question?

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

Ask Backwork about J3380 Sign up free

`J3380`, Injection, vedolizumab, intravenous, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3380`, Injection, vedolizumab, intravenous, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3380, Injection, vedolizumab, intravenous, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3380, Injection, vedolizumab, intravenous, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3380`, Injection, vedolizumab, intravenous, 1 mg

`J3380`, Injection, vedolizumab, intravenous, 1 mg