J0121, Injection, omadacycline, 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation required for initial authorization includes age ≥18 and non-pregnant status if of childbearing potential, with CABP diagnosis and specified requirements.
Key Coverage Criteria
- Omadacycline requires prior authorization by HealthPartners Pharmacy Administration.
5 Active Policies
BCBSMS-L-5-01-558-77198733E2, Nuzyra (omadacycline)
MS
BCBSMS-S-5-01-558-FEB6723BCD, State and School Employees' Health Insurance Plan - Nuzyra (omadacycline)
MS
HEALTHPARTNERS-CC-ENTRY-217831, Omadacycline (Nuzyra) – Minnesota Healthcare Programs
MULTI
POINT32HEALTH-PMNG-17096, Nuzyra (omadacycline) tablets
MULTI
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