Does J1746 require prior authorization?

No, J1746 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J1746?

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

Provider attestation that the patient has multi-drug resistant HIV-1 infection (required for initial therapy)
Provider confirmation/documentation that the patient has been prescribed an optimized background antiretroviral regimen containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility (required for initial and continuation therapy)
For continuation therapy: documentation that the patient has previously received Trogarzo (ibalizumab-uiyk)
For continuation therapy: provider confirmation/documentation that the patient has achieved a clinically significant viral response to Trogarzo therapy (e.g., documented viral load response)

Trogarzo (ibalizumab-uiyk) is proven and medically necessary for the treatment of multi-drug resistant human immunodeficiency virus (HIV) in patients who meet all of the following criteria:
For initial therapy, all of the following:
Diagnosis of HIV-1 infection
Provider attestation that the patient has multi-drug resistant HIV-1 infection
Provider confirms that the patient has been prescribed an optimized background antiretroviral regimen, containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility
Trogarzo (ibalizumab-uiyk) initial and maintenance dosing is in accordance with the US Food and Drug Administration prescribing information

UHC-POL-trogarzo-ibalizumab-uiyk — Trogarzo (Ibalizumab-Uiyk)

UMR-POL-UMR-trogarzo-ibalizumab-uiyk — Trogarzo (Ibalizumab-Uiyk)

SUREST-POL-SUREST-trogarzo-ibalizumab-uiyk — Trogarzo (Ibalizumab-Uiyk)

BCBSIL-RX501.099 — Ibalizumab-uiyk

BCBSMT-RX501.099 — Ibalizumab-uiyk

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