Does J9311 require prior authorization?

Yes, J9311 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9311?

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

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`J9311`, Injection, rituximab 10 mg and hyaluronidase

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

For initial therapy, one of the following: o Prescriber attests dosing is in accordance with the United States Food and Drug Administration (FDA) approved labeling; or o For indications without FDA approved dosing, prescriber attests there is published clinical evidence to support the dosing
For continuation of therapy, both of the following: Documentation of a positive clinical response; and One of the following: ▪ Prescriber attests dosing is in accordance with the United States Food and Drug Administration (FDA) approved labeling; or ▪ For indications without FDA approved dosing, prescriber attests there is published clinical evidence to support the dosing
Prior authorization required for all rituximab uses except FDA-approved oncology uses for Ruxience/Truxima and for Rituxan Hycela; AR for RA/off-label.
The provided policy text does not specify required documentation (e.g., prior authorization forms, specific tests); documentation requirements for coverage (especially for off-label uses) should be confirmed with the A/B MAC.

Key Coverage Criteria

Coverage is provided for injectable oncology medications listed in the NCCN Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B as proven and medically necessary; categories with 3 are unproven and not medically necessary.
Medically necessary Rituximab products are covered when (a) there is a history of intolerance, contraindication, or serious adverse event to the non-preferred products Riabni, Ruxience, or Truxima, and (b) the physician attests that the same intolerance, contraindication, or serious adverse event would not be expected with the non-preferred product.
Coverage is provided for injectable oncology medications listed in the NCCN Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B as proven and medically necessary; Category 3 is unproven and not medically necessary. If NCCN has no compendium, coverage determinations are based on FDA labeling.
Treatment with Rituxan or other rituximab products is medically necessary for the indications specified in this policy when both of the following criteria are met: History of intolerance, contraindication, or serious adverse event to Riabni, Ruxience, or Truxima; and Physician attests that, in their clinical opinion, the same intolerance, contraindication, or serious adverse event would not be expected to occur with the respective non-preferred product
Criteria for coverage of Ruxience/Truxima include: hematologist/oncologist prescription for NHL, CLL, autoimmune hemolytic anemia, or ITP; and/or GPA/MPA with age ≥2 years and specialist prescription with glucocorticoids; and/or moderate to severe RA with documented DMARD trial/failure criteria, and FDA-approved dosing regimen; and no concurrent other biologic agent.
Rituxan Hycela coverage without prior authorization when prescribed by hematologist/oncologist for NHL subtypes (FL, DLBCL) and CLL.

20 Active Policies

ARKBLUE-RITUXIMAB-E-G-RITUXAN-AND-BIOSIMILARS-AND-RITUXI-FB69FA5ACF, Rituximab (e.g., Rituxan) and Biosimilars and Rituximab/Hyaluronidase (e.g., Rituxan Hycela)- Oncologic Indications

PALMETTO-JJ-L35026, Rituximab

PALMETTO-JM-L35026, Rituximab

HEALTHPARTNERS-CC-ENTRY-228488, Oncology** - rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela, and Riabni) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-AENTRY-046128, Oncology** - rituximab (Rituxan, Ruxience, Truxima, Rituxan Hycela, and Riabni)

MULTI

BCBSND-RITUXIMAB-RITUXAN-TRUXIMA-AND-RITUXIMAB-FC9D96D3E5, Rituximab Rituxan Truxima AND Rituximab AND Hyaluronidase Human Rituxan Hycela

BCBSNJ-DRUGS-043-F492DC55BC, Rituximab (Rituxan), Rituximab-abbs (Truxima), Rituximab-pvvr (Ruxience), and Rituximab/hyaluronidase (Rituxan Hycela)

MODA-RITUXANHYCELA-51345FC913, Rituxan Hycela (rituximab and hyaluronidase human)

HEALTHNET_OR-HNOR-RITUXIMAB-HYALURONIDASE-RITUXAN-HYCELA-CP-PHAR-260-3F0FFBE55D, Rituximab/Hyaluronidase (Rituxan Hycela); CP.PHAR.260

IBX-COMMERCIAL-08-00-50AF-C912D250F8, Rituximab (Rituxan) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela)

IBX-MA-PPO-HOST-MA08-022Q-1F31A3C9F7, Rituximab (Rituxan) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela)

IBX-MEDICARE-ADVANTAGE-MA08-022T-3A34276AEE, Rituximab (Rituxan) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela)

UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

UMR-POL-UMR-rituxan-rituximab, Rituximab (Riabni, Rituxan, Ruxience, & Truxima)

SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

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

SUREST-POL-SUREST-rituxan-rituximab, Rituximab (Riabni, Rituxan, Ruxience, & Truxima)

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

AMERIHEALTH-COMMERCIAL-08-00-50AF-5F0CB5B056, Rituximab (Rituxan) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-022T-8EC788F8E5, Rituximab (Rituxan) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela)

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J9311, Injection, rituximab 10 mg and hyaluronidase