26 commercial payer policies list J0175. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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26 policies from 18 payers
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (donanemab-azbt) | Dec 1, 2025 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Kisunla (donanemab-azbt) Medicare AdvantageEffective 07/01/2025 - 06/30/2026 | Jul 1, 2025 | Prior auth requiredInferred from policy title |
| Kisunla (donanemab-azbt)Effective 12/01/2024 - 11/30/2025 | Dec 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab-azbt | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab-azbt | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab-azbt | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab-azbt | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (donanemab-azbt) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Kisunla (donanemab) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (Donanemab-Azbt) | Feb 1, 2026 | Covered |
| Kisunla (Donanemab-Azbt) – Individual Exchange Medical Benefit Drug Policy | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab (e.g., Kisunla) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| KISUNLA | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| KISUNLA (DONANEMAB-AZBT) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab-azbt (Kisunla) | Dec 31, 2024 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (Donanemab-Azbt) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab (Kisunla); CP.PHAR.594 | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Donanemab-azbt (Kisunla) – Minnesota Health Care Programs | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Anti-amyloid-β monoclonal antibodies: donanemab-azbt (Kisunla) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (donanemab-azbt) (PG238, Ver. 2) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (Donanemab-Azbt) | Feb 1, 2026 | Covered |
| Policy | Effective | Status of J0175 |
|---|---|---|
| Kisunla (Donanemab-Azbt) | Feb 1, 2026 | Covered |