Does Q5106 require prior authorization?

Yes, Q5106 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5106?

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

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`Q5106`, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

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

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
Hemoglobin value with date (to document hemoglobin thresholds for initial authorization and for patients currently receiving ESA therapy).

Key Coverage Criteria

ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
FDA-approved non-oncology indications
Anemia associated with chronic kidney disease (CKD) in individuals on dialysis
Anemia associated with chronic kidney disease (CKD) in individuals not on dialysis

20 Active Policies

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents

BCBSLA-00210-60A0AB5406, 00210 Erythropoiesis-Stimulating Agents (ESA’s): epoetin alfa (Epogen and Procrit), epoetin alfa-epbx (Retacrit), darbepoetin alfa (Aranesp), and pegylated epoetin beta (Mircera)

MODA-ESA-2188222DD4, Epoetin alfa: Epogen; Procrit; Retacrit

HEALTHNET_OR-HNOR-EPOETIN-ALFA-EPOGEN-PROCRIT-EPOETIN-ALFA-EPBX-RETACRIT-C-7FFD127D80, Epoetin Alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit); CP.PHAR.237

EVICORE-MEDICAL_DRUG-98D845C4B804, Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncologyEffective 10/01/2026

EVICORE-MEDICAL_DRUG-B3B872C20E2F, Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncology

SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents

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

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Ask Backwork about Q5106 Sign up free

Q5106, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

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

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
Hemoglobin value with date (to document hemoglobin thresholds for initial authorization and for patients currently receiving ESA therapy).

Key Coverage Criteria

ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
FDA-approved non-oncology indications
Anemia associated with chronic kidney disease (CKD) in individuals on dialysis
Anemia associated with chronic kidney disease (CKD) in individuals not on dialysis

20 Active Policies

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents

MODA-ESA-2188222DD4, Epoetin alfa: Epogen; Procrit; Retacrit

HEALTHNET_OR-HNOR-EPOETIN-ALFA-EPOGEN-PROCRIT-EPOETIN-ALFA-EPBX-RETACRIT-C-7FFD127D80, Epoetin Alfa (Epogen, Procrit), Epoetin alfa-epbx (Retacrit); CP.PHAR.237

EVICORE-MEDICAL_DRUG-98D845C4B804, Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncologyEffective 10/01/2026

EVICORE-MEDICAL_DRUG-B3B872C20E2F, Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncology

SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents

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

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about Q5106 Sign up free

`Q5106`, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q5106`, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q5106, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

Q5106, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`Q5106`, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000

`Q5106`, Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000