HCPCS
J9155
1 mg = 1 unit
Phase 1
Identify what you're billing
Confirm the right code, dose, and clinical context (antagonist vs agonist) before billing.
The no-testosterone-flare advantage Clinical, verified May 2026
Firmagon's pharmacology eliminates the initial testosterone surge that plagues GnRH agonists — a major clinical and billing differentiator.
All GnRH analogs ultimately suppress testosterone, but they get there in opposite ways. GnRH agonists (Lupron, Eligard, Trelstar, Zoladex) initially overstimulate the GnRH receptor before downregulating it — producing a 1–2 week testosterone surge that can transiently worsen prostate cancer. GnRH antagonists (Firmagon, oral Orgovyx) directly block the receptor and suppress testosterone within days without surge.
Why the flare matters clinically: in patients with high tumor burden, the testosterone
surge can cause:
- Bone metastasis pain flare — sudden worsening of skeletal pain
- Spinal cord compression — tumor expansion in vertebral metastases
- Urinary tract obstruction — growth of locally advanced primary tumor
- Cardiovascular events — some studies suggest reduced CV events with antagonists
Practical billing implication: no antiandrogen needed
With Lupron/Eligard, clinicians typically co-administer 2–4 weeks of an oral antiandrogen (bicalutamide, flutamide) starting before or with the first injection to block the flare. This is not needed with Firmagon — one reason oncology practices preferentially choose Firmagon for patients with bone metastases or where flare would be catastrophic.
Documentation tip: When choosing Firmagon over Lupron/Eligard for a flare-vulnerable
patient (bone mets, spinal cord compression risk, urinary obstruction), document the clinical rationale
in the chart. Some commercial payer step-therapy protocols prefer GnRH agonists by default; documenting
the flare-avoidance rationale supports a Firmagon-specific PA.
GnRH analog class comparison Verified May 2026
All approved injectable + oral GnRH analogs for prostate cancer ADT. Firmagon is the original injectable antagonist.
| Drug | HCPCS | Class | Route / interval | Flare? |
|---|---|---|---|---|
| Firmagon (degarelix) Ferring |
J9155 |
GnRH antagonist | SC abdomen — 240 mg loading then 80 mg monthly | No flare |
| Lupron Depot (leuprolide) AbbVie |
J1950 |
GnRH agonist | IM — 7.5 mg q1mo / 22.5 mg q3mo / 30 mg q4mo / 45 mg q6mo | Yes (1–2 wk surge) |
| Eligard (leuprolide) Tolmar |
J9217 |
GnRH agonist | SC depot — 7.5 mg q1mo / 22.5 mg q3mo / 30 mg q4mo / 45 mg q6mo | Yes (1–2 wk surge) |
| Trelstar (triptorelin) Verity Pharma |
J3315 |
GnRH agonist | IM — 3.75 mg q1mo / 11.25 mg q3mo / 22.5 mg q6mo | Yes (1–2 wk surge) |
| Zoladex (goserelin) TerSera |
J9202 |
GnRH agonist | SC implant — 3.6 mg q1mo / 10.8 mg q3mo | Yes (1–2 wk surge) |
| Orgovyx (relugolix) Sumitomo |
N/A (pharmacy) | GnRH antagonist (oral) | Oral — 360 mg loading day 1, then 120 mg PO daily | No flare |
Class summary: Firmagon = original GnRH antagonist on the medical benefit (J-code billed
by the physician practice). Orgovyx = newer oral GnRH antagonist on the pharmacy benefit (filled by
specialty pharmacy, no J-code). All other approved injectable ADT options are GnRH agonists, all of
which produce testosterone flare.
Site-of-care implications: Firmagon (SC abdomen) and Eligard (SC depot) can be administered
in office without infusion-suite chair time. Lupron Depot (IM) and Trelstar (IM) are also office-based.
Zoladex (SC implant) is also office-based. None require IV access. All are minimal-time SC/IM injections
once reconstituted/prepared.
Dosing & unit math FDA label verified May 2026
Fixed dosing, not weight-based. Same regimen across patients.
Loading dose (initiation)
- 240 mg SC total, administered as two separate 120 mg SC injections at two different sites in the abdomen, both given on the same visit
- Each 120 mg vial is reconstituted separately with sterile water (per kit instructions) immediately before injection
- 1 mg = 1 unit — bill 240 units of J9155 on the loading visit
- Bill CPT 96402 once for the visit (not twice for two injections)
Maintenance dose
- 80 mg SC monthly (single injection in abdomen), starting 28 days after the loading dose
- Reconstitute one 80 mg vial with sterile water immediately before injection
- Bill 80 units of J9155 per monthly visit
- Continue indefinitely as long as castrate testosterone level (<50 ng/dL) is maintained and clinical benefit persists
Worked example — first-year billing
# Loading visit (Day 0)
Drug units billed: 240 (J9155)
HCPCS: J9155 · Modifier: JZ · Vials: 2 × 120 mg
Admin: 96402 × 1 (chemo SC, hormonal antineoplastic)
# Maintenance visits (Day 28, 56, 84, ... — 11 visits in first year)
Drug units per visit: 80 (J9155)
HCPCS: J9155 · Modifier: JZ · Vial: 1 × 80 mg
Admin: 96402 × 1
# Year-1 totals
Total visits: 12 (1 loading + 11 maintenance)
Total drug units billed: 1,120 (240 + 11 × 80)
Total drug cost (Q2 2026 ASP+6%): ~$4,993 before sequestration
Drug units billed: 240 (J9155)
HCPCS: J9155 · Modifier: JZ · Vials: 2 × 120 mg
Admin: 96402 × 1 (chemo SC, hormonal antineoplastic)
# Maintenance visits (Day 28, 56, 84, ... — 11 visits in first year)
Drug units per visit: 80 (J9155)
HCPCS: J9155 · Modifier: JZ · Vial: 1 × 80 mg
Admin: 96402 × 1
# Year-1 totals
Total visits: 12 (1 loading + 11 maintenance)
Total drug units billed: 1,120 (240 + 11 × 80)
Total drug cost (Q2 2026 ASP+6%): ~$4,993 before sequestration
No premedication required
No routine premedication. Most importantly, no antiandrogen co-administration is needed (unlike GnRH agonists where 2–4 weeks of bicalutamide is typical for flare protection).
NDC reference FDA NDC Directory verified May 2026
| NDC (10/11-digit) | Package | Use |
|---|---|---|
55566-8303-01 |
120 mg single-dose vial kit (lyophilized powder + sterile water diluent) | Loading dose — 2 kits per loading visit (240 mg total) |
55566-8203-01 |
80 mg single-dose vial kit (lyophilized powder + sterile water diluent) | Maintenance dose — 1 kit per monthly visit |
Use the NDC that matches the actual vial strength used on the visit. The 120 mg kit is for
loading (2 used on day 0); the 80 mg kit is for maintenance (1 per monthly visit thereafter). Using the
wrong NDC will trigger NDC-vs-units mismatch denials.
Reconstitution note: Each kit contains both the lyophilized powder vial and the sterile
water diluent vial. Reconstitute only at point of administration; the reconstituted product must be
injected within 1 hour and is not stable for storage.
Phase 2
Code the claim
Hormonal chemo SC code 96402 is the right admin code for prostate cancer indication.
Administration codes CPT verified May 2026
Firmagon is a hormonal antineoplastic for prostate cancer — CPT 96402 is the right primary code.
| Code | Description | When to use |
|---|---|---|
96402 |
Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic | Primary code for Firmagon. Bill once per visit (not per injection) even when two injections are given on the loading day. |
96401 |
Chemotherapy administration, SC/IM; non-hormonal anti-neoplastic | Not appropriate for Firmagon — degarelix is a hormonal antineoplastic. Use 96402. |
96372 |
Therapeutic, prophylactic, or diagnostic injection; SC or IM | Some payers accept 96372 for non-oncology contexts. For the FDA-labeled prostate cancer indication, 96402 is preferred. Verify per payer. |
Why 96402 (not 96401 or 96372): CPT 96402 is the dedicated code for hormonal antineoplastic
SC/IM administration. Degarelix is a GnRH receptor antagonist used to suppress testosterone in prostate
cancer — a hormonal antineoplastic. Most major payers (UHC, Aetna, BCBS) and Medicare LCDs reimburse
96402 at a higher rate than 96372 because it is recognized as oncology administration.
Loading dose — bill 96402 ONCE. Two SC injections at two different abdominal sites
on the same visit are still a single administration encounter. Do not bill 96402 × 2.
Modifiers CMS verified May 2026
JZ — required on virtually every claim
Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. Firmagon doses are fixed, not weight-based: the 240 mg loading dose uses two 120 mg vials with no waste; the 80 mg maintenance dose uses one 80 mg vial with no waste. JZ applies to virtually every Firmagon claim.
JW — rarely applicable
JW reports the discarded portion of a single-dose vial. Because Firmagon dosing is fixed and the available vial sizes (80 mg, 120 mg) match the prescribed doses exactly, partial-vial waste should not occur. JW is unlikely to apply — if you find yourself needing JW for Firmagon, double-check that the right vial strength was selected.
Modifier 25 — same-day E/M
Use modifier 25 on the E/M code when a significant, separately identifiable evaluation and management service is performed on the same day as the injection. Routine pre-injection clinical assessment is bundled.
340B modifiers (JG, TB)
For 340B-acquired Firmagon, follow your MAC's current 340B modifier policy. Ferring's billing guidance does not provide 340B-specific instructions.
ICD-10-CM — prostate cancer FY2026 verified May 2026
Firmagon is FDA-labeled only for advanced prostate cancer. Use C61 as the primary diagnosis with relevant secondary codes.
| Code | Description | Use |
|---|---|---|
C61 | Malignant neoplasm of prostate | Primary diagnosis on every Firmagon claim |
C77.5 | Secondary malignant neoplasm of intrapelvic lymph nodes | Pelvic nodal mets |
C79.51 | Secondary malignant neoplasm of bone | Bone metastases (common Firmagon-preferred scenario) |
C79.52 | Secondary malignant neoplasm of bone marrow | Marrow involvement |
C79.81 | Secondary malignant neoplasm of breast (males) | Rare |
C79.82 | Secondary malignant neoplasm of genital organs | Local extension |
C79.89 | Secondary malignant neoplasm of other specified sites | Other distant mets |
R97.21 | Rising PSA following treatment for prostate cancer | Biochemical recurrence (use with C61) |
Z19.1 | Hormone sensitive malignancy status | Status code; supports ADT medical necessity |
Z19.2 | Hormone resistant malignancy status | Castration-resistant disease (supports continued ADT during second-line therapy) |
Firmagon is NOT FDA-approved for benign indications. Off-label use (e.g., suppression
for non-prostate-cancer endocrine indications) will not have an applicable C-code and is unlikely to be
covered. Document a prostate cancer diagnosis (C61) on every claim.
Site of care & place of service Verified May 2026
Firmagon is a 1–2 minute SC injection (after reconstitution). It does not require infusion-suite chair time and is well-suited for office-based administration. Site-of-care UM is less aggressive than with IV biologics, but commercial plans still prefer office over hospital outpatient.
| Setting | POS | Claim form | Payer steering |
|---|---|---|---|
| Urology / oncology office | 11 | CMS-1500 / 837P | Preferred by commercial UM |
| Ambulatory infusion suite | 49 | CMS-1500 / 837P | Acceptable |
| Oncology ASC | 24 | CMS-1500 / 837P | Acceptable |
| Hospital outpatient (on-campus) | 22 | UB-04 / 837I | Disfavored for routine maintenance |
| Hospital outpatient (off-campus PBD) | 19 | UB-04 / 837I | Disfavored for routine maintenance |
| Patient home | 12 | CMS-1500 (with home injection vendor) | Possible but uncommon — reconstitution complexity |
Office-based by default: Most Firmagon doses are administered in urology or oncology
offices. The reconstitution step (mix powder + diluent immediately before injection) is straightforward
but does require trained nursing staff — which is why home administration is uncommon despite the
small SC injection volume.
Claim form field mapping Ferring 2026
From Ferring HCP coding & coverage guidance for Firmagon.
| Information | CMS-1500 box | Notes |
|---|---|---|
| NPI | 17b | Rendering provider |
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | N4 + vial NDC + ML + total reconstituted volume per kit |
| HCPCS J9155 + JZ | 24D (drug line) | JZ on virtually every claim (no waste) |
| Drug units | 24G | 240 (loading) or 80 (maintenance) |
| CPT 96402 (admin line) | 24D (admin line) | Once per visit, even with 2 loading injections |
| ICD-10 | 21 | C61 primary; secondary mets codes if applicable |
| PA number | 23 | Required by most major commercial payers |
Phase 3
Get paid
PA + advanced prostate cancer dx + testosterone/PSA monitoring drives most approvals.
Payer policy snapshot Reviewed May 2026
Most major payers cover Firmagon for advanced prostate cancer with a baseline testosterone level and PSA monitoring plan.
| Payer | PA? | Key requirements | Step therapy |
|---|---|---|---|
| UnitedHealthcare Oncology Med Coverage Policy |
Yes | Advanced prostate cancer dx (C61), baseline testosterone, PSA monitoring plan; flare-vulnerable patient documentation supports antagonist choice over agonist | Some plans require trial of GnRH agonist first unless flare-avoidance is documented |
| Aetna Medical Drug Policy |
Yes | Advanced prostate cancer dx; baseline T & PSA; QT/electrolyte assessment | Variable by plan |
| BCBS plans Vary by plan |
Yes | Generally aligned with NCCN Prostate Cancer Guidelines | Plan-specific |
| Medicare (LCDs) MAC-specific |
Generally no PA | FDA-approved indication (advanced prostate cancer) with appropriate ICD-10 | None |
Required clinical documentation
- Baseline testosterone level (to confirm non-castrate at start, then track suppression)
- Baseline PSA + monitoring plan (typically q3 months)
- Baseline ECG + electrolyte assessment (QT/QTc prolongation risk)
- Baseline LFTs + periodic monitoring (hepatic dysfunction risk)
- Bone density assessment baseline + periodic for long-term ADT
Step therapy
Some commercial plans require trial of a GnRH agonist (Lupron, Eligard) first. Bypass is supported when: bone metastases present, spinal cord compression risk, urinary obstruction, prior intolerance to agonist, or other clinical reason flare avoidance is critical. Document these in the PA.
Medicare reimbursement CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter.
Q2 2026 payment snapshot — J9155
Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions
ASP + 6%
$4.458
per mg / per unit
240 mg loading dose
$1,069.92
240 units × ASP+6%
80 mg monthly
$356.64
80 units × ASP+6%
Annualized cost (Year 1): 1 loading dose ($1,069.92) + 11 monthly maintenance doses
($3,923.04) = ~$4,993/year (Medicare ASP+6%). After ~2% sequestration: ~$4,892/year
actual paid. Subsequent years: 12 maintenance doses = ~$4,280/year.
Coverage
No NCD specific to degarelix. Coverage falls under MAC LCDs for hormonal antineoplastics + the generic drug-coverage framework. All MACs cover J9155 for FDA-approved advanced prostate cancer indication with appropriate ICD-10 (C61).
Code history
- J9155 — permanent code, "Degarelix injection" · 1 mg = 1 unit
Patient assistance — Ferring Pharmaceuticals Ferring verified May 2026
- Ferring Pharmaceuticals Patient Assistance / Firmagon Co-pay Program: 1-888-FERRING (1-888-337-7464) — benefits investigation, prior authorization assistance, copay assistance for eligible commercially-insured patients (excludes Medicare, Medicaid, federal program patients), and free product for uninsured/underinsured patients meeting income requirements
- Foundations: for Medicare patients, refer to PAN, HealthWell, CancerCare, Patient Advocate Foundation — verify open prostate cancer / hormone therapy funds quarterly
- Web: firmagon.com (HCP and patient resources)
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance,
and OOP max? Run a CareCost Estimate — J9155 pre-loaded.
Phase 4
Fix problems
Wrong admin code (96401 instead of 96402) and missing JZ are the most common Firmagon-specific denials.
Common denials & how to fix them
| Denial reason | Common cause | Fix |
|---|---|---|
| Wrong admin code (96401) | Non-hormonal SC chemo code billed for hormonal antineoplastic | Resubmit with 96402 (hormonal SC). Degarelix is a GnRH antagonist for prostate cancer — hormonal antineoplastic. |
| Wrong admin code (96372) | Therapeutic SC injection code billed instead of chemo SC | Resubmit with 96402 for the FDA-labeled prostate cancer indication. 96402 reimburses higher and is the correct oncology administration code. |
| JZ missing | Single-dose vial claim without JZ modifier | Resubmit with JZ. Required since 7/1/2023 on every claim with no waste. |
| NDC-vs-units mismatch | Wrong NDC strength (80 mg vs 120 mg) selected for the dose billed | Loading visit: NDC 55566-8303-01 (120 mg) × 2 = 240 units. Maintenance: NDC 55566-8203-01 (80 mg) × 1 = 80 units. |
| Step-therapy denial | Plan requires GnRH agonist trial first | Submit appeal with documentation of flare-vulnerable status (bone mets, spinal cord compression risk, urinary obstruction) or prior agonist intolerance. Reference NCCN Prostate Cancer Guidelines. |
| 96402 billed twice on loading day | Coder billed once per injection instead of once per visit | Resubmit with 96402 × 1. Two SC injections at two sites are still one administration encounter. |
| ICD-10 mismatch | Off-label or non-prostate diagnosis | Firmagon is approved only for advanced prostate cancer. Confirm C61 primary diagnosis. |
| Site of care (HOPD) | HOPD administration on commercial plan with site-of-care UM | Move to office (POS 11) or AIC (POS 49). Submit medical necessity letter if HOPD required. |
Frequently asked questions
What is the HCPCS code for Firmagon?
Firmagon (degarelix SC) is billed under HCPCS J9155 — "Degarelix injection."
Each milligram equals one billable unit. The 240 mg loading dose bills as 240 units (administered as
two separate 120 mg SC injections at two different abdominal sites) and the 80 mg monthly maintenance
dose bills as 80 units.
How is Firmagon dosed?
Loading dose: 240 mg SC, administered as two separate 120 mg SC injections at two different sites in the abdomen, both given on the same visit. Maintenance: 80 mg SC monthly thereafter (single injection in the abdomen). Firmagon is reconstituted from lyophilized powder with sterile water immediately before administration.
What administration CPT do I use for Firmagon?
CPT 96402 — "Chemotherapy administration, subcutaneous or intramuscular; hormonal
anti-neoplastic." Firmagon is a hormonal antineoplastic (GnRH antagonist) used for prostate cancer, so
96402 is the correct admin code. Some payers accept 96372 (therapeutic SC) for non-oncology contexts,
but for the FDA-labeled prostate cancer indication 96402 is the standard. Bill 96402 once per visit even
when two injections (loading dose) are administered on the same date — it is not billed per injection.
Does Firmagon cause testosterone flare like Lupron?
No. Firmagon is a GnRH receptor antagonist, not a GnRH agonist. GnRH agonists like Lupron Depot (J1950) and Eligard (J9217) cause an initial 1–2 week testosterone surge (flare) before suppressing testosterone, which can transiently worsen prostate cancer. Firmagon directly blocks GnRH receptors and suppresses testosterone within days without flare. This is a major clinical advantage in patients with bone metastases, spinal cord compression risk, or urinary obstruction. Patients on Firmagon do NOT need the antiandrogen co-administration (e.g., bicalutamide for the first 2–4 weeks) typically used to block flare with Lupron/Eligard.
Do I bill JZ or JW for Firmagon?
Bill JZ on virtually every Firmagon claim. Firmagon doses are fixed (240 mg loading uses
two 120 mg vials with no waste; 80 mg maintenance uses one 80 mg vial with no waste). JW is
rarely if ever applicable because dosing is not weight-based. CMS requires one of JZ or JW on every
single-dose container claim since July 1, 2023.
What is the Medicare reimbursement for J9155?
For Q2 2026, the Medicare Part B payment limit for J9155 is $4.458 per mg (ASP + 6%). The 240 mg loading dose reimburses at approximately $1,069.92; the 80 mg monthly maintenance dose at approximately $356.64. First-year cost (1 loading + 11 monthly maintenance): approximately $4,993. Sequestration (~2%) reduces actual paid to roughly ASP + 4.3%.
How does Firmagon compare to Lupron, Eligard, and Orgovyx?
All four are androgen deprivation therapies for prostate cancer. Firmagon (J9155, degarelix) is the original GnRH antagonist — SC monthly with no testosterone flare. Lupron Depot (J1950, leuprolide) and Eligard (J9217, leuprolide) are GnRH agonists — Lupron is IM monthly/q3mo/q4mo/q6mo, Eligard is SC depot. Trelstar (J3315, triptorelin) is IM agonist monthly. Zoladex (J9202, goserelin) is a SC implant agonist. Orgovyx (relugolix) is a newer oral GnRH antagonist on the pharmacy benefit (not the medical benefit). All GnRH agonists cause testosterone flare; only the antagonists (Firmagon, Orgovyx) avoid it.
Does Firmagon require ECG monitoring?
Yes. The FDA label warns of QT/QTc prolongation. Baseline ECG and electrolyte assessment are recommended before starting therapy, with periodic monitoring during treatment, particularly in patients with congenital long QT syndrome, electrolyte abnormalities, congestive heart failure, or those taking other QT-prolonging medications. LFTs should also be monitored at baseline and periodically due to risk of hepatic dysfunction.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- Ferring Pharmaceuticals — Firmagon HCP page (coding, dosing, patient support)
- DailyMed — FIRMAGON (degarelix) Prescribing Information
- CMS — Medicare Part B Drug ASP Pricing File
- SEER CanMED — HCPCS J9155 reference
- NCCN Clinical Practice Guidelines in Oncology — Prostate Cancer
- AUA Guideline — Advanced Prostate Cancer
- UnitedHealthcare — Oncology Medication Clinical Coverage Policy
- Aetna CPB — Hormone Therapy for Prostate Cancer
- FDA National Drug Code Directory
- Ferring — Firmagon Patient Support / Co-pay Program (1-888-FERRING)
About this page
We maintain this page as a living reference. Medicare ASP pricing is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Coding and policy content is reviewed at least quarterly and updated whenever a source document changes.
Found an error? Email hello@carecostestimate.com.
Refresh cadence
| Element | Cadence | How it's refreshed |
|---|---|---|
| Medicare ASP pricing | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Payer policies (UHC, Aetna, BCBS) | Semi-annual | Manual review against published payer policy documents. |
| HCPCS / CPT / modifier rules | Annual | Reviewed against CMS HCPCS quarterly files and AMA CPT releases. |
| NDC, dosing, FDA label, GnRH class context | Event-driven | Tied to manufacturer document version + FDA label revision date + new drug entrants in the GnRH class (e.g., Orgovyx oral antagonist). |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA, CMS,
manufacturer, payer documents — all linked above). Editorial review in progress. Until that review is complete, treat this as a draft reference and verify each cited
source for high-stakes claims.
Change log
- — Initial publication. ASP data: Q2 2026. Manufacturer source: Ferring 2026. FDA label: current revision (NDA 022201, originally approved Dec 2008). GnRH antagonist class context including Orgovyx oral comparison.
Methodology
Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File. Payer policies are read directly from each payer's published medical/pharmacy policy documents. Dosing and indication content is verified against the current FDA label revision. Class context (GnRH agonist vs antagonist) is verified against NCCN and AUA prostate cancer guidelines.