Does J1426 require prior authorization?

No, J1426 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J1426?

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

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Amondys 45 (casimersen) may be covered for the treatment of Duchenne muscular dystrophy (DMD) in patients who meet all of the following criteria: Initial Therapy Diagnosis of Duchenne muscular dystrophy by, or in consultation with, a neurologist with expertise in the diagnosis of DMD; and Submission of medical records confirming the mutation amenable to exon 45 skipping; and One of the following: 6MWT ≥ 300 meters while walking independently prior to beginning Amondys 45 therapy; or ambulatory w [...]

UHC-POL-amondys, Amondys 45 (Casimersen)

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-amondys, Amondys 45 (Casimersen)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-amondys, Amondys 45 (Casimersen)

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