J2802, Injection, romiplostim, 1 microgram
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that the requested therapy is proven effective for the relevant diagnosis or procedure.
- For drug therapy, documentation of proposed dose, frequency, and duration consistent with at least one authoritative source.
- References/citations to supporting sources such as FDA labeling, MCG care guidelines, DrugDex, NCCN Guidelines/Compendia, or peer-reviewed literature.
- Provide citation(s) to the relevant standard medical reference compendium entry demonstrating the use is recognized as safe and effective.
Key Coverage Criteria
- Coverage for services and supplies is determined by the member's benefit plan, summary plan description, or contract.
- Coverage of any FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by HHS.
- Coverage of any FDA‑approved drug for an off‑label use when safety and efficacy for that use are confirmed in two articles from major peer‑reviewed professional medical journals.
- To increase survival in adults and pediatric individuals (including term neonates) acutely exposed to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome [HS-ARS]).
- Adults with immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins (IVIG), or splenectomy.
- Pediatric patients ≥1 year old with ITP for at least 6 months who have had an insufficient response to corticosteroids, immunoglobulins (IVIG), or splenectomy.
16 Active Policies
RX501.157, Romiplostim
BCBSIL-RX501.157, Romiplostim
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.157, Romiplostim
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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