Does J9264 require prior authorization?

Yes, J9264 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9264?

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

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`J9264`, Injection, paclitaxel protein-bound particles, 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

When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.

Key Coverage Criteria

Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.

20 Active Policies

ARKBLUE-NAB-PACLITAXEL-E-G-ABRAXANE-359D00459A, Nab-Paclitaxel (e.g., Abraxane)

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A52450, Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

BCBSM-2070042-1AD4063D40, NAB-PACLITAXEL; PACLITAXEL PROTEIN-BOUND PARTICLES

POINT32HEALTH-MDMNG-24056, Abraxane (paclitaxel protein bound)

MULTI

BCBSNJ-DRUGS-082-764D03C4F8, Paclitaxel Protein-Bound Particles (Abraxane)

HEALTHNET_OR-HNOR-PACLITAXEL-PROTEIN-BOUND-ABRAXANE-CP-PHAR-176-F1CACBC26E, Paclitaxel Protein-Bound (Abraxane); CP.PHAR.176

MODA-CUSTOM-MODA-MRXM-PACLITAXEL-ALBUMIN-BOUND-E-CCE79C8DD6, Paclitaxel Albumin-Bound: Abraxane; Paclitaxel Albumin-Bound

IBX-MEDICARE-ADVANTAGE-MA08-049R-86DBC00BEC, Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane for Injectable Suspension)

IBX-COMMERCIAL-08-00-90V-1AC19DB25B, Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane for Injectable Suspension)

BCBSOK-RX502.061, Oncology Medications

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

AMERIHEALTH-COMMERCIAL-08-00-90V-014CEB04FC, Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane for Injectable Suspension)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-049R-0533705820, Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane for Injectable Suspension)

BCBSTN-2a7cc49102, Paclitaxel (Albumin-Bound) (Abraxane; Paclitaxel Albumin-Bound)

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

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

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J9264, Injection, paclitaxel protein-bound particles, 1 mg