J2796, Injection, romiplostim, 10 micrograms
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Key Coverage Criteria
- HS-ARS coverage criterion for Romiplostim
- ITP indication requiring insufficient response to standard therapies
- Romiplostim may be medically necessary to increase survival in adults and pediatric individuals (including term neonates) acutely exposed to myelosuppressive doses of radiation (HS-ARS).
- Romiplostim may be medically necessary for the treatment of thrombocytopenia in adults with ITP who had insufficient response to corticosteroids, immunoglobulins, or splenectomy; or pediatric patients 1 year and older with ITP for at least 6 months with insufficient response to corticosteroids, immunoglobulins, or splenectomy.
- Romiplostim is medically necessary for treatment of thrombocytopenia due to immune thrombocytopenia (ITP) in adults with insufficient response to corticosteroids, immunoglobulins, or splenectomy, or in pediatric patients 1 year and older with ITP for at least 6 months and insufficient response to those therapies.
- Romiplostim is medically necessary for treatment of immune thrombocytopenia (ITP) in adults with insufficient response to corticosteroids, immunoglobulins, or splenectomy; or in pediatric patients aged 1 year and older with ITP for at least 6 months and insufficient response to these therapies.
5 Active Policies
BCBSIL-RX501.157, Romiplostim
BCBSMT-RX501.157, Romiplostim
BCBSNM-RX501.157, Romiplostim
BCBSOK-RX501.157, Romiplostim
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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