Q5134 — Injection, natalizumab-sztn (tyruko), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Evidence that the requested therapy is proven effective for the relevant diagnosis or procedure.
- For drug therapy, documentation that the proposed dose, frequency, and duration align with recommendations in at least one authoritative source.
- Supportive references such as FDA-approved labeling and/or nationally recognized authoritative references (examples: MCG care guidelines, DrugDex (IIa+), NCCN Guidelines/Compendia).
- Peer-reviewed scientific literature and generally accepted standards of medical care may be used to support medical necessity.
Key Coverage Criteria
- Coverage for a service or supply is determined by the member's benefit plan, summary plan description, or contract.
- State regulations may mandate coverage or impose additional requirements for certain services.
- For HCSC members residing in Ohio, any FDA‑approved drug is covered when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services.
- For HCSC members residing in Ohio, an FDA‑approved drug is covered for an off‑label indication when medical literature support consists of two articles from major peer‑reviewed professional medical journals demonstrating the proposed off‑label use is generally safe and effective.
- Monotherapy with natalizumab (Tysabri or Tyruko) for treatment of adult patients (≥18 years) with relapsing forms of multiple sclerosis when all specified criteria are met
- Relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing‑remitting MS, active secondary progressive MS) for patients being considered for natalizumab therapy.
9 Active Policies
BCBSIL-RX501.059 — Natalizumab and Associated Biosimilar(s)
BCBSMT-RX501.059 — Natalizumab and Associated Biosimilar(s)
BCBSNM-RX501.059 — Natalizumab and Associated Biosimilar(s)
BCBSOK-RX501.059 — Natalizumab and Associated Biosimilar(s)
BCBSIL-ADM1001.034 — Specialty Medication Administration Site of Care
Related Codes
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