Does J9376 require prior authorization?

No, J9376 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J9376?

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

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`J9376`, Injection, pozelimab-bbfg, 1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Patients receiving a complement inhibitor must be vaccinated for MenACWY and MenB per ACIP at least 2 weeks before the first Veopoz dose.
Submission of medical records (e.g., chart notes, laboratory values) confirming a biallelic loss-of-function mutation in the CD55 gene; and

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Covered when the equipment, drug, device, or supply has FDA marketing approval for the intended use; items without FDA marketing approval are considered experimental/investigational/unproven and are not a covered indication.
Medically necessary for treatment of adult and pediatric patients (≥1 year) with CD-55 deficient protein-losing enteropathy (CHAPLE disease) when the listed criteria are met.
Requires clinical history of PLE and genotype-confirmed biallelic CD55 loss-of-function mutation.
Requires hypoalbuminemia defined as serum albumin ≤ 3.2 g/dL.
Requires one or more of: abdominal pain, diarrhea, peripheral edema, or facial edema within the last 6 months.

17 Active Policies

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UHC-POL-veopoz, Veopoz (Pozelimab-Bbfg)

BCBSIL-ADM1001.028, Inside the U.S. Food and Drug Administration (FDA)

BCBSIL-RX501.182, Pozelimab-bbfg

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-ADM1001.028, Inside the U.S. Food and Drug Administration (FDA)

BCBSMT-RX501.182, Pozelimab-bbfg

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-ADM1001.028, Inside the U.S. Food and Drug Administration (FDA)

BCBSNM-RX501.182, Pozelimab-bbfg

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-ADM1001.028, Inside the U.S. Food and Drug Administration (FDA)

BCBSOK-RX501.182, Pozelimab-bbfg

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-veopoz, Veopoz (Pozelimab-Bbfg)

SUREST-POL-SUREST-veopoz, Veopoz (Pozelimab-Bbfg)

`J9376`, Injection, pozelimab-bbfg, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

J9376, Injection, pozelimab-bbfg, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`J9376`, Injection, pozelimab-bbfg, 1 mg