14 commercial payer policies list J0642. 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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14 policies from 14 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 J0642 |
|---|---|---|
| Levoleucovorin Calcium (e.g., Khapzory) | 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 J0642 |
|---|---|---|
| Oncology Medications |
| Jul 1, 2026 |
| Covered |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J0642 |
|---|---|---|
| KHAPZORY (LEVOLEUCOVORIN) | 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 J0642 |
|---|---|---|
| Levoleucovorin (Fusilev), Levoleucovorin (Khapzory), Levoleucovorin | Dec 1, 2016 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Cigna MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Q4 - 2026 JHP MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Levoleucovorin (Fusilev and Khapzory) | 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 J0642 |
|---|---|---|
| Levoleucovorin: Fusilev; Khapzory | 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 J0642 |
|---|---|---|
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of J0642 |
|---|---|---|
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |