Moda Health · PayerPolicy · MODA-TRASTUZUMAB-IV
Source checked August 2, 2026 · Open the payer’s source
Summary of the payer’s published policy. Not a coverage determination — confirm with Moda Health before submitting.
Listed in Moda Health's provider indexes for Oregon, Alaska, Idaho, Texas. The document does not establish the member's state or line of business.
Not for Medicare decisions. The document says: The preceding information is intended for non-Medicare coverage determinations.
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Listed on Moda Health's provider indexes: Oregon, Alaska, Idaho, Texas
Free account. Policy pages stay open to everyone.
Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
| Code | Code system | Status in this policy |
|---|---|---|
| J9355 | HCPCS | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Q5112 | HCPCS | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Q5113 | HCPCS | Covered with conditions |
| Q5114 | HCPCS | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Q5116 | HCPCS | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
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| Q5117 | HCPCS | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
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