Does J9316 require prior authorization?

Yes, J9316 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9316?

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

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`J9316`, Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 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

Procedure codes listed are for general reference and may not be all-inclusive.
Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.
Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
Prior authorization is required by HealthPartners Pharmacy Administration.

Key Coverage Criteria

Coverage of injectable oncology medications is based on NCCN Compendium Categories of Evidence and Consensus (1, 2A, 2B = proven/medically necessary; 3 = unproven/not medically necessary); if NCCN is unavailable, base decisions on FDA labeling.
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.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
12-month authorization for neoadjuvant treatment of HER2-positive breast cancer in combination with chemotherapy for locally advanced, inflammatory, or early-stage disease (greater than 2 cm or node-positive).

20 Active Policies

ARKBLUE-PERTUZUMAB-TRASTUZUMAB-AND-HYALURONIDASE-ZZXF-E-58B4D7524D, Pertuzumab, trastuzumab and hyaluronidase-zzxf (e.g., PHESGO)

BCBSM-2132114-F477DFF5B5, PHESGO (PERTUZUMAB, TRASTUZUMAB AND HYALURONIDASE-ZZXF) J3590

HEALTHPARTNERS-CC-ENTRY-233979, Oncology - pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo) – Minnesota Health Care Programs

MULTI

POINT32HEALTH-MDMNG-24096, Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)

MULTI

BCBSND-PERTUZUMAB-TRASTUZUMAB-AND-HYALURONIDASE-9FA532D01E, Pertuzumab Trastuzumab AND Hyaluronidase Zzxf Phesgo

BCBSNJ-DRUGS-011-749DD9CCDF, Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri), Ado-trastuzumab emtansine (Kadcyla), Trastuzumab-pkrb (Herzuma), Trastuzumab-dttb (Ontruzant), Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta), Trastuzumab-qyyp (Trazimera), Trastuzumab-anns (Kanjinti), Fam-trastuzumab deruxtecan-nxki (Enhertu), Pertuzumab (Perjeta), and Pertuzumab, Trastuzumab, and hyaluronidase-zzxf (Phesgo)

MODA-PHESGO-09A45DE62C, Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf)

HEALTHNET_OR-HNOR-PERTUZUMAB-TRASTUZUMAB-HYALURONIDSE-ZZXF-PHESGO-CP-PHAR-EFD0D9B44C, Pertuzumab-trastuzumab-hyaluronidse-zzxf (Phesgo); CP.PHAR.501

IBX-COMMERCIAL-08-01-72B-14C73342A7, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo)

IBX-MEDICARE-ADVANTAGE-MA08-129B-B0F0BABE3B, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo)

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

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

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

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

AMERIHEALTH-COMMERCIAL-08-01-72B-5AF23D9DEE, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-129B-319A3E691A, Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo)

BCBSTN-e8fb3a5eea, Pertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo)

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

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

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J9316, Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg