Does J9011 require prior authorization?

Yes, J9011 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9011?

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

HCPCS/CPT

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Non-small cell lung cancer: Authorization of 12 months may be granted for treatment of non-small cell lung cancer when all of the following criteria are met: The disease is locally advanced or metastatic; The tumor is EGFR mutation positive; The member has received prior treatment with EGFR-directed therapy (e.g., osimertinib) and platinum-based chemotherapy.
Indication: Coverage requires oncologist prescription, patient age >=18, unresectable or metastatic HR-positive, HER2-negative breast cancer, progression on endocrine therapy, prior chemotherapy for unresectable/metastatic disease, intolerance to Enhertu/Trodelvy demonstrated, ECOG 0-1, and use within FDA-approved dosing for Datroway.
In Breast Cancer, for datopotamab deruxtecan-dlnk therapy: the patient must have HER2-negative disease (IHC 0, 1+, or ISH-negative), HR-positive disease, unresectable or metastatic disease, has received prior endocrine-based therapy, and has been treated with chemotherapy in the unresectable or metastatic setting; therapy is restricted to patients with a contraindication or intolerance to fam-trastuzumab deruxtecan-nxki (if not previously used).

ARKBLUE-DATOPOTAMAB-DERUXTECAN-DLNK-E-G-DATROWAY-8146A11699, Datopotamab deruxtecan-dlnk (e.g., Datroway)

HEALTHPARTNERS-CC-ENTRY-284657, Oncology - datopotamab deruxtecan-dlnk (Datroway)

MULTI

HEALTHNET_OR-HNOR-DATOPOTAMAB-DERUXTECAN-DLNK-DATROWAY-CP-PHAR-715-5222336F2A, Datopotamab Deruxtecan-dlnk (Datroway); CP.PHAR.715

MODA-MODA-MPS-DATROWAY-B1F2548F68, Datroway (datopotamab deruxtecan-dlnk)

IBX-COMMERCIAL-08-02-41-4676A312F4, Datopotamab deruxtecan (Datroway)

IBX-MEDICARE-ADVANTAGE-MA08-185-657A6C8205, Datopotamab deruxtecan (Datroway)

BCBSTN-ab5ea3fbc5, Datopotamab Deruxtecan-dlnk (Datroway)

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

AMERIHEALTH-COMMERCIAL-08-02-41-23FFF8AF17, Datopotamab deruxtecan (Datroway)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-185-D22195173E, Datopotamab deruxtecan (Datroway)

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf