Does J1577 require prior authorization?

No, J1577 does not require prior authorization (high confidence). Code is covered without prior authorization.

`J1577`, Injection, immune globulin (qivigy), 100 mg

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Initial therapy requires (a) diagnosis and (b) medical records documenting severity and diagnostic evidence, and (c) prescriber attests dosing per FDA labeling (or alternative evidence for dosing).

Coverage for the following preferred immune globulin products Bivigam® (IV), Cutaquig® (SC), Cuvitru® (SC), Flebogamma® DIF (IV), Gammagard® Liquid (IV, SC), Gammagard® S/D (IV), Gammaked™ (IV, SC), Gammaplex® (IV), Gamunex®-C (IV, SC), Hizentra® (SC), HyQvia® (SC), Octagam® (IV), Privigen® (IV), and Xembify® (SC) is contingent on criteria in the General Requirements and Diagnosis-Specific Requirements sections.
Treatment with a non-preferred immune globulin is medically necessary for the indications specified in this policy when one of the following criteria is met: Both of the following: Documentation of a trial of all of the preferred immune globulin products resulting in minimal clinical response to therapy and residual disease activity; and Physician attests that in their clinical opinion, the clinical response would be expected to be superior with the requested non-preferred product, than experien [...]
Non-preferred immune globulin product may be approved if: (a) documentation of trial of all preferred products with minimal response and physician attestation that non-preferred would be superior; or (b) documentation of intolerance or contraindication to all preferred products and physician attestation that same intolerance would not occur with the non-preferred product.

UHC-POL-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

UMR-POL-UMR-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

SUREST-POL-SUREST-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)

Ask Verity about documentation requirements, denial risks, or coverage in your state.