Does J1627 require prior authorization?

Yes, J1627 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1627?

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

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

For non-preferred product approval: documentation of a prior trial (adequate dose and duration) of a preferred NK1 RA or 5HT3 RA and documentation of minimal clinical response to that trial.
Alternatively, for non-preferred product approval: documentation of history of intolerance, contraindication, or adverse event to a preferred NK1 RA or 5HT3 RA, plus physician attestation that the same intolerance/contraindication/adverse event would not be expected with the requested non-preferred product.
Physician attestation (statement in medical record) supporting expectation of superior clinical response with non-preferred product (when trial/failure route used) or supporting that intolerance/contraindication to preferred product would not occur with non-preferred product.

Prevention of chemotherapy-induced nausea and vomiting (CINV) due to High Emetic Risk parenteral anticancer agents when an NK1 RA (e.g., Emend, Cinvanti, Varubi) is used in combination with a 5HT3 RA.
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when an NK1 RA is used in combination with a 5HT3 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
Prevention of CINV due to High Emetic Risk parenteral anticancer agents when a 5HT3 RA (Aloxi, Kytril, Sustol, Zofran) is used in combination with an NK1 RA.
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used (standalone option for moderate risk).
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used in combination with an NK1 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
Treatment of breakthrough nausea and/or vomiting due to anticancer agent(s) (5HT3 RAs listed as indicated for this scenario).

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

BCBSOK-RX502.061, Oncology Medications

UMR-POL-UMR-antiemetics-oncology, Antiemetics for Oncology

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