Pemetrexed (J9305) Billing & Coding Guide | Alimta + Generics

Phase 1 Identify what you're billing Pick the right J-code, confirm renal eligibility, and verify vitamin pretreatment status.

J9305 vs J9304 vs J9322 — pick the right pemetrexed code CMS HCPCS verified May 2026

Three distinct HCPCS codes exist for pemetrexed. The J-code MUST match the specific product (and NDC) actually administered.

HCPCS code disambiguation: J9305 NOS generic vs J9304 Alimta originator vs J9322 Pemfexy.
HCPCS	Product	Manufacturer	Use today
`J9305`	"Injection, pemetrexed, NOS, 10 mg"	Hospira, Apotex, Fresenius Kabi, Sandoz, multiple generics	Most common billing today. Default for any non-Alimta, non-Pemfexy generic.
`J9304`	"Injection, pemetrexed (Alimta), 10 mg"	Eli Lilly (originator)	Declining post-LOE (2022). Brand still on some payer formularies; use only when Alimta NDC was actually dispensed.
`J9322`	"Injection, pemetrexed (Pemfexy), 10 mg"	Eagle Pharmaceuticals	Premixed/ready-to-dilute formulation. Use only when Pemfexy NDC was dispensed; payers often prefer J9305 for cost.

NDC must match J-code. Submitting J9304 with a generic Hospira NDC will trigger an NDC/HCPCS mismatch denial and potential audit recoupment. Most pharmacy management systems can be configured to auto-route to J9305 when a generic NDC is dispensed.

Payer preference is heavily toward J9305. Major payers (UnitedHealthcare, Aetna, BCBS) typically prefer generic pemetrexed (J9305) over Alimta originator (J9304) and Pemfexy (J9322) for cost reasons. Some plans require step therapy: try J9305 generic first; J9304 / J9322 only with documented intolerance or formulary exception.

Dosing & unit math FDA label verified May 2026

From FDA prescribing information — dosing is identical across all approved indications.

Adult dosing — all approved indications

500 mg/m² IV over ~10 minutes, Day 1 of each 21-day cycle
Calculate dose using actual body surface area (BSA), Mosteller or Du Bois formula per institutional standard
No dose escalation; no induction; same dose for monotherapy, combo with platinum, or combo with pembrolizumab + platinum
1 unit = 10 mg — bill (mg administered) ÷ 10 rounded per local policy

Worked example — standard dose for 1.7 m² BSA patient

# BSA-based dose calculation Dose: 500 mg/m² \times 1.7 m² = 850 mg # Vial draw (most economical) 1 \times 500 mg vial + 4 \times 100 mg vials = 900 mg drawn Administered: 850 mg Wasted: 50 mg (5 units) # Claim lines Line 1: J9305 + JZ — 85 units (administered) Line 2: J9305 + JW — 5 units (wasted, single-dose vial) Admin: 96413 (chemo IV, single substance, ~10 min) # Q2 2026 reimbursement (ASP+6%) Drug: 90 units \times ~$4.038 = ~$363.42 per cycle (administered + wasted) Annualized at 17 cycles (q3w \times 12 mo): ~$6,178/year drug cost

Worked example — 2.0 m² BSA patient (no waste scenario)

# BSA-based dose calculation Dose: 500 mg/m² \times 2.0 m² = 1,000 mg # Vial draw 2 \times 500 mg vials = 1,000 mg drawn Administered: 1,000 mg \cdot Wasted: 0 mg # Claim line (single line, JZ only) J9305 + JZ — 100 units

Combination regimens

PEM-CIS (1L mesothelioma + non-squamous NSCLC): pemetrexed 500 mg/m² + cisplatin 75 mg/m² (cisplatin starts ~30 min after pemetrexed completes)
PEM-CARB: pemetrexed 500 mg/m² + carboplatin AUC 5–6 (similar sequencing)
KEYNOTE-189 (1L non-squamous NSCLC SOC): pembrolizumab 200 mg + pemetrexed 500 mg/m² + carboplatin/cisplatin q3w × 4 cycles, then maintenance pembrolizumab + pemetrexed q3w — see Keytruda billing guide (J9271)
Maintenance: pemetrexed 500 mg/m² q3w monotherapy after platinum-based induction (4–6 cycles)

Vitamin supplementation protocol — mandatory FDA label verified May 2026

Required by FDA label for ALL pemetrexed indications. Skipping causes severe (sometimes fatal) myelosuppression and GI toxicity. Most common pemetrexed-related sentinel event.

Pretreatment vitamin supplementation is NOT optional. The vitamin protocol mitigates antifolate-mediated toxicity. Patients who miss vitamin supplementation experience severe myelosuppression, Grade 3+ GI events, and increased treatment-related mortality. Document folic acid + B12 dates in chart before every infusion.

Agent	Dose	Timing	Purpose
Folic acid	350–1,000 mcg PO daily	Start ≥7 days before first dose; continue throughout therapy + 21 days after last dose	Mitigate myelosuppression + GI toxicity
Vitamin B12	1,000 mcg IM (cyanocobalamin)	Within 1 week before first dose; then every 9 weeks during therapy	Mitigate myelosuppression
Dexamethasone	4 mg PO BID	Days −1, 0, +1 of each pemetrexed cycle	Mitigate skin rash (bullous/exfoliative reactions)

Operational cadence

Pre-cycle 1 checklist: folic acid started ≥7 days prior + B12 IM given within 1 week prior + dexamethasone dispensed for Days −1/0/+1
Each subsequent cycle: verify folic acid still daily + dexamethasone for Days −1/0/+1
Every 9 weeks: next B12 IM dose (typically administered in clinic same day as a pemetrexed cycle to keep cadence)
Discontinuation: continue folic acid for 21 days after last pemetrexed dose

Billing the supplementation

Folic acid: patient-purchased OTC; not separately billable
B12 IM injection: bill J3420 (cyanocobalamin 1,000 mcg up to) + admin code 96372 (therapeutic IM/SC injection)
Dexamethasone: patient-purchased PO; not separately billable on chemo day

Renal contraindication — CrCl <45 mL/min FDA label verified May 2026

CONTRAINDICATION: Pemetrexed is renally cleared. CrCl <45 mL/min (estimated by Cockcroft-Gault) is a contraindication to pemetrexed administration per FDA label. Acute renal failure has been reported. Document baseline CrCl + CrCl before EVERY cycle.

Renal function workflow

Baseline: serum creatinine + Cockcroft-Gault CrCl before first cycle. Patients with CrCl <45 mL/min cannot receive pemetrexed.
Pre-cycle (every cycle): serum creatinine within 7 days of planned infusion; recalculate Cockcroft-Gault CrCl. Hold/withdraw if CrCl drops below 45 mL/min.
CrCl 45–79 mL/min: dose may proceed at full 500 mg/m² but with increased toxicity monitoring; consider dose reduction per institutional policy and patient-specific factors.
CrCl ≥80 mL/min: standard dose with routine monitoring.

Cockcroft-Gault formula reminder

# Male CrCl = [(140 - age) \times weight kg] \div (72 \times serum creatinine mg/dL) # Female CrCl = above \times 0.85

NSAIDs can rapidly drop CrCl below the 45 mL/min threshold. Counsel patients on the NSAID restriction at every cycle, and re-check renal function if patient reports any NSAID exposure in the prior week. See NSAID restriction.

NSAID restriction — drug interaction FDA label verified May 2026

NSAIDs reduce renal pemetrexed clearance and increase myelosuppression risk. Counsel about OTC NSAIDs at every visit.

NSAID interaction is clinically significant. Patients often self-medicate with OTC ibuprofen (Advil, Motrin) or naproxen (Aleve) for arthritis pain or post-cycle aches. This must be actively asked about at every cycle, not assumed.

NSAID type	Examples	Restriction window
Short half-life NSAIDs	ibuprofen, ketorolac, diclofenac, indomethacin	Avoid for 2 days before, the day of, and 2 days after each pemetrexed dose
Long-acting NSAIDs	piroxicam, meloxicam, naproxen, nabumetone	Avoid for 5 days before through 2 days after each pemetrexed dose
Acetaminophen	Tylenol, paracetamol	Acceptable for analgesia — not an NSAID

Patient counseling script

"Do NOT take Advil, Motrin, ibuprofen, Aleve, naproxen, or any prescription anti-inflammatory in the days around your chemo. Acetaminophen (Tylenol) is OK."
"Tell us if you have taken any pain reliever in the past week so we can check your kidney function."
"This restriction applies to every cycle, not just the first one."

NDC reference FDA NDC Directory verified May 2026

Multiple manufacturers; NDC must match the J-code billed. Sample NDCs below; verify against the actual product label at dispense.

HCPCS	Product / Manufacturer	Sample NDC	Vial
`J9304`	Alimta — Eli Lilly (originator)	`00002-7623-01` (100 mg) / `00002-7640-01` (500 mg)	100 mg / 500 mg lyophilized SDV
`J9305`	Pemetrexed — Hospira (Pfizer)	Verify per current Pfizer label	100 mg / 500 mg lyophilized SDV
`J9305`	Pemetrexed — Apotex / Fresenius Kabi / Sandoz	Verify per dispensed manufacturer label	100 mg / 500 mg lyophilized SDV (some pre-mixed RTU)
`J9322`	Pemfexy — Eagle Pharmaceuticals	Verify per current Eagle label	500 mg / 20 mL premixed RTU (25 mg/mL)

Use carton-level NDC, not vial-level. Submit the 11-digit NDC from the carton on the claim form (24A shaded area on CMS-1500). Vial-level NDC will trigger denial. With multiple generic manufacturers in the supply chain, verify the dispensed manufacturer's NDC at every order — do not rely on a static reference.

Phase 2 Code the claim True chemotherapy admin codes apply. JW for vial waste is the rule, not the exception.

Administration codes CPT verified May 2026

Pemetrexed is true cytotoxic chemotherapy. Use chemo admin codes (96409 family).

Code	Description	When to use
`96413`	Chemotherapy administration, IV infusion technique; up to 1 hour, single or initial substance/drug	Primary code for pemetrexed. ~10-min infusion fits well within the 1-hour window.
`96415`	Chemotherapy administration, IV infusion; each additional hour	Rarely needed for pemetrexed monotherapy (10-min infusion). May apply when extended hydration is required for combo with cisplatin.
`96417`	Chemotherapy administration; each additional sequential infusion (different substance/drug), up to 1 hour	For combo regimens: pembrolizumab as second/subsequent infusion after pemetrexed (KEYNOTE-189).
`96365` / `96366`	Therapeutic IV infusion (non-chemo)	NOT appropriate. Pemetrexed is cytotoxic chemotherapy — use chemo admin codes.
`96372`	Therapeutic IM/SC injection	For B12 IM injection (separate line, not pemetrexed itself).

Sequencing with platinum (PEM-CIS, PEM-CARB): pemetrexed is given first as the initial substance under 96413, followed by ~30 min wait, then platinum as the next sequential infusion under 96417. With cisplatin, factor in pre/post hydration time. With pembrolizumab + platinum (KEYNOTE-189), pembrolizumab typically goes first as the initial 96413 substance, then pemetrexed and platinum as sequential 96417 substances per institutional protocol.

Modifiers CMS verified May 2026

JZ — required when no waste

Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. For pemetrexed, JZ applies when the drawn volume exactly matches the administered dose — rare, because BSA-based dosing usually doesn't hit clean 100 / 500 mg multiples.

JW — required when waste occurs (most pemetrexed claims)

Pemetrexed dosing is BSA-based (500 mg/m²) but vials come in fixed 100 mg and 500 mg sizes. Most cycles produce some waste. Bill the discarded portion on a separate claim line with the JW modifier.

JW worked example

# 1.7 m² BSA patient, 850 mg dose Vials drawn: 1 \times 500 mg + 4 \times 100 mg = 900 mg Administered: 850 mg = 85 units Wasted: 50 mg = 5 units # Claim form (CMS-1500) Line 1: J9305 JZ-substituted-with-JW-when-waste \cdot 85 units (administered) \cdot modifier JW Line 2: J9305 \cdot 5 units (wasted) \cdot modifier JW # Per CMS billing convention Administered units use base J9305 code; JW reports the wasted units only. One of JZ or JW must be on every J9305 claim with single-dose vials.

Common error: Forgetting to bill the JW waste line. CMS audits often catch this. Wasted drug is fully reimbursable when reported correctly — failing to bill it leaves money on the table AND violates the single-dose container reporting requirement.

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 infusion (e.g., toxicity assessment cycle visit). Routine pre-infusion clinical assessment is bundled with the infusion.

340B modifiers (JG, TB)

For 340B-acquired pemetrexed, follow your MAC's current 340B modifier policy. Generic pemetrexed is commonly purchased through 340B at significant discount; 340B status must be reported per local rules.

ICD-10-CM by indication FY2026 verified May 2026

Non-squamous histology must be documented in chart for NSCLC indications. Mesothelioma codes specify anatomic site.

Indication	ICD-10 family	Notes
Non-squamous NSCLC (1L combo with platinum)	`C34.x`	4th character by lobe; histology must be non-squamous — document in chart
Non-squamous NSCLC (maintenance)	`C34.x`	After 4–6 cycles platinum-based induction; document maintenance intent
Non-squamous NSCLC (single-agent post-prior chemo)	`C34.x`	2L+; document prior chemo + progression
Non-squamous NSCLC + pembrolizumab + platinum (KEYNOTE-189)	`C34.x`	Current 1L SOC for non-squamous NSCLC PD-L1 unselected
Malignant pleural mesothelioma	`C45.0`	1L combo with cisplatin (PEM-CIS); document pleural origin
Mesothelioma of pericardium	`C45.2`	Off-label/per NCCN; verify payer coverage
Mesothelioma of peritoneum	`C45.1`	Off-label/per NCCN; verify payer coverage
Mesothelioma of other sites	`C45.7`	Per FDA label expanded to other sites
Mesothelioma, unspecified	`C45.9`	Use only if site not yet documented; prefer site-specific code

NSCLC histology is the load-bearing detail. Pemetrexed is FDA-approved for non-squamous NSCLC only. Squamous NSCLC (C34.x with squamous histology in path report) is a coverage exclusion. Pathology report MUST be available in the medical record at PA submission. UnitedHealthcare and Aetna both check pathology reports for NSCLC pemetrexed PAs.

Mesothelioma: the original FDA approval was malignant pleural mesothelioma (C45.0) in combo with cisplatin. Other anatomic sites are sometimes covered per NCCN guidelines but require per-payer verification.

Site of care & place of service Verified May 2026

Pemetrexed is true cytotoxic chemotherapy — site-of-care steering is less aggressive than for immune checkpoint inhibitors, but UHC, Aetna, and BCBS commercial plans still steer toward office and ambulatory infusion centers over hospital outpatient departments for cost. Combo regimens with cisplatin require longer chair time (hydration) and may justify infusion center over office.

Setting	POS	Claim form	Payer steering
Physician oncology office	11	CMS-1500 / 837P	Preferred by commercial UM (monotherapy / maintenance)
Ambulatory infusion suite (AIC)	49	CMS-1500 / 837P	Preferred by commercial UM (combo with platinum)
Oncology ASC	24	CMS-1500 / 837P	Acceptable
Hospital outpatient (on-campus)	22	UB-04 / 837I	Disfavored for monotherapy; acceptable for cisplatin combo (hydration)
Hospital outpatient (off-campus PBD)	19	UB-04 / 837I	Disfavored after first 3 months
Patient home	12	CMS-1500 (with home infusion)	Rare for cytotoxic chemo

Claim form field mapping CMS verified May 2026

Information	CMS-1500 box	Notes
NPI	17b	Rendering provider
NDC qualifier + 11-digit NDC + UoM + qty	24A shaded area	N4 + carton NDC + ML + total volume drawn
HCPCS J9305 + JZ (no waste) or JW (waste)	24D (drug line)	Almost always JW given BSA dosing + fixed vial sizes
Drug units administered	24G	(mg administered) ÷ 10
Drug units wasted (separate line)	24G (separate line)	(mg wasted) ÷ 10 with JW
CPT 96413 (admin line)	24D (admin line)	Initial chemo IV substance, ≤1 hour
CPT 96417 (combo additional substance)	24D (admin line, additional)	For platinum or pembrolizumab in same encounter
ICD-10	21	C34.x non-squamous NSCLC OR C45.x mesothelioma
PA number	23	Required by all major payers

Phase 3 Get paid PA requires histology + renal function + vitamin documentation. Generic preference is universal.

Payer policy snapshot Reviewed May 2026

Generic pemetrexed (J9305) is the preferred product across all major payers. Alimta originator (J9304) and Pemfexy (J9322) typically require step-through.

Payer	PA?	Documentation requirements	J-code preference
UnitedHealthcare Oncology Med Coverage Policy	Yes	Non-squamous NSCLC histology confirmation OR mesothelioma dx + renal function (CrCl) + concurrent platinum partner (1L) + vitamin supplementation documented	J9305 generic preferred; J9304/J9322 require formulary exception
Aetna CPB + Medical Drug policies	Yes	Histology + CrCl ≥45 mL/min + vitamin documentation; line of therapy	J9305 generic preferred
BCBS plans Vary by plan	Yes	Generally aligned with NCCN NSCLC + Mesothelioma guidelines; require histology + renal function	J9305 generic preferred; some plans cover all three at parity
Medicare (MAC LCDs)	No (FFS)	On-label use with appropriate ICD-10 + documentation; coverage under generic Part B drug framework	Reimbursement at ASP+6% per current quarter

Step therapy

Step therapy through generic J9305 is essentially universal before approving J9304 (Alimta originator) or J9322 (Pemfexy premixed). Documented intolerance to a specific generic excipient or a clinical reason for premixed RTU formulation (e.g., compounding pharmacy capacity constraints) may justify J9322.

Medicare reimbursement CMS Q2 2026 (live)

Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter.

Q2 2026 payment snapshot — J9305

Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions

ASP + 6%

$4.038

per 10 mg unit

850 mg dose (1.7 m² BSA)

$343.23

85 units × ASP+6%

1,000 mg dose (2.0 m² BSA)

$403.80

100 units × ASP+6%

Annualized cost: 850 mg q3w × ~17 cycles/year = ~$5,835/year drug cost for an average BSA patient on monotherapy or maintenance (Medicare ASP+6%, before sequestration). Combo regimens add cisplatin/carboplatin and pembrolizumab costs separately. Generic pemetrexed pricing is dramatically lower than pre-genericization Alimta cost (Alimta pre-LOE was >$300 per 10 mg unit; generic ASP+6% has dropped >98%).

Coverage

No NCD specific to pemetrexed. Coverage falls under MAC LCDs for biologics/oncology + the generic drug-coverage framework. All MACs cover J9305 for FDA-approved on-label indications with appropriate ICD-10, histology documentation, and renal function evidence.

Code history

J9304 — Alimta-specific code, originator era (Eli Lilly)
J9305 — NOS pemetrexed (generic), used as default post-LOE (2022)
J9322 — Pemfexy-specific (Eagle Pharmaceuticals premixed RTU)

Patient assistance Verified May 2026

Generic manufacturer support: most generic pemetrexed manufacturers (Hospira/Pfizer, Apotex, Fresenius Kabi, Sandoz) offer a patient support hotline — verify per dispensed label. Generic copay support is typically narrower than originator programs.
Lilly Cares Foundation (Alimta legacy): 1-800-545-6962 / lillycares.com — free Alimta for uninsured / underinsured patients meeting income criteria; relevant for J9304 patients still on originator
Eagle Pharmaceuticals (Pemfexy): verify current Eagle copay assistance and PAP via product website
Foundations: for Medicare patients, refer to PAN, HealthWell, CancerCare — verify open NSCLC + mesothelioma funds quarterly
340B: generic pemetrexed is commonly purchased through 340B at significant discount; eligible facilities should verify 340B sourcing

Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance, and OOP max? Run a CareCost Estimate — J9305 pre-loaded with vial-waste modeling.

Phase 4 Fix problems Unit-basis errors, missing JW waste, missing histology docs, and renal-function gaps are the top four.

Common denials & how to fix them

Denial reason	Common cause	Fix
Units billed = mg administered (10x overcharge)	Biller assumed 1 mg = 1 unit (the mAb convention)	Resubmit with units = mg ÷ 10. 1 unit of J9305 = 10 mg.
NDC/HCPCS mismatch	J9304 billed but generic NDC dispensed (or vice versa)	Resubmit with J-code matching the actual product NDC. Use J9305 for any non-Alimta, non-Pemfexy generic.
Wasted drug not billed (JW missing)	BSA-based dose with vial waste, only administered units submitted	Add separate JW line for the discarded units. Wasted drug is reimbursable when reported.
JZ missing (no waste scenario)	Single-dose vial claim without JZ	Resubmit with JZ. One of JZ or JW required since 7/1/2023.
NSCLC histology not documented	PA submitted with C34.x but no path report or histology field	Submit pathology report confirming non-squamous histology. Squamous NSCLC is excluded.
Renal function not documented	No baseline or pre-cycle CrCl in submission	Submit Cockcroft-Gault CrCl from within 7 days; CrCl ≥45 mL/min required.
Vitamin supplementation not documented	Folic acid / B12 dates missing from chart	Document folic acid start date (≥7 days before first dose) + B12 IM date (within 1 week before first dose). Audit-vulnerable.
Wrong admin code (96365)	Therapeutic IV billed instead of chemo IV	Resubmit with 96413. Pemetrexed is true cytotoxic chemotherapy.
Wrong NDC format (vial-level)	Vial NDC submitted instead of carton NDC	Use carton-level 11-digit NDC.
Step therapy not satisfied (Alimta or Pemfexy)	J9304 or J9322 submitted without prior J9305 generic trial	Try J9305 generic first; submit formulary exception with documented intolerance/clinical rationale for non-generic.

Frequently asked questions

What is the HCPCS code for pemetrexed?

Generic pemetrexed (and most current pemetrexed billing) uses HCPCS J9305 — "Injection, pemetrexed, not otherwise specified, 10 mg." One billable unit equals 10 mg, NOT 1 mg. Two related codes exist: J9304 for brand Alimta originator (Eli Lilly, declining usage post-LOE), and J9322 for Pemfexy (Eagle Pharmaceuticals premixed RTU formulation).

How many units of J9305 do I bill for a 500 mg/m² dose?

Convert mg to units by dividing by 10. For a 1.7 m² BSA patient: 500 × 1.7 = 850 mg administered = 85 units. Vials drawn: 1 × 500 mg + 4 × 100 mg = 900 mg total. Bill 85 units administered + 5 units wasted (separate JW line). For a 2.0 m² patient: 1,000 mg = 100 units. Always document BSA and round per institutional policy.

Is vitamin supplementation actually required before pemetrexed?

Yes — vitamin pretreatment is mandatory per the FDA label and is enforced by every major payer. Folic acid 350–1,000 mcg PO daily must start at least 7 days before the first pemetrexed dose, continued throughout therapy and 21 days after the last dose. Vitamin B12 1,000 mcg IM must be given within 1 week before the first pemetrexed dose, then every 9 weeks during therapy. Dexamethasone 4 mg PO BID Days −1, 0, +1 of each cycle mitigates skin rash. Skipping vitamin pretreatment causes severe myelosuppression and GI events.

What is the renal function contraindication for pemetrexed?

Pemetrexed is renally cleared and is contraindicated in patients with creatinine clearance (CrCl) less than 45 mL/min as estimated by Cockcroft-Gault. Document CrCl at baseline AND before every cycle. Patients with CrCl 45–79 mL/min require dose review and increased toxicity monitoring. Acute renal failure has been reported. NSAIDs further compromise renal clearance.

What is the NSAID restriction with pemetrexed?

Avoid short-half-life NSAIDs (ibuprofen, ketorolac) for 2 days before, the day of, and 2 days after each pemetrexed dose. Avoid long-acting NSAIDs (piroxicam, meloxicam, naproxen) for 5 days before through 2 days after. Counsel patients about OTC NSAIDs (Advil, Motrin, Aleve) at every cycle. Acetaminophen is acceptable.

What administration CPT do I use for pemetrexed?

CPT 96413 — "Chemotherapy administration, IV infusion technique; up to 1 hour, single or initial substance/drug." Pemetrexed is true cytotoxic chemotherapy infused IV over ~10 minutes. Add 96417 for sequential additional substances in combo regimens (cisplatin, carboplatin, or pembrolizumab).

What is the Medicare reimbursement for J9305?

For Q2 2026, the Medicare Part B payment limit for J9305 is approximately $4.038 per 10 mg unit (ASP + 6%). The 500 mg/m² dose for a 1.7 m² BSA patient (~850 mg / 85 units) reimburses at approximately $343.23 per cycle. Annualized at 17 cycles/year: ~$5,835/year drug cost. Generic pricing is dramatically lower than pre-genericization Alimta. Sequestration (~2%) reduces actual paid to roughly ASP + 4.3%.

Can I bill J9304 (Alimta) instead of J9305 (NOS) if I dispensed a generic?

No. J9304 is brand-Alimta-specific (originator, Eli Lilly NDC). J9305 is the NOS generic code and is the appropriate code for generic pemetrexed from Hospira, Apotex, Fresenius Kabi, Sandoz, and other generic manufacturers. J9322 is reserved for Pemfexy (Eagle Pharmaceuticals premixed RTU). NDC must match the J-code; mismatches trigger denials and audit recoupment.

Reference Sources & methodology Every claim on this page is sourced. Methodology and review history below.

Source documents

DailyMed — Pemetrexed Prescribing Information (multiple labelers)
FDA-approved label, originator Alimta NDA 021462 (Feb 2004) + multiple generic ANDAs (2022+)
FDA Alimta label PDF (originator, NDA 021462)
Originator FDA label including vitamin supplementation protocol, renal contraindication, NSAID restriction
CMS — Medicare Part B Drug ASP Pricing File
Q2 2026 quarterly file, effective April 1 – June 30, 2026
SEER CanMED — HCPCS J9305 reference
SEER CanMED — HCPCS J9304 (Alimta) reference
SEER CanMED — HCPCS J9322 (Pemfexy) reference
NCCN Clinical Practice Guidelines — Non-Small Cell Lung Cancer
KEYNOTE-189 1L SOC for non-squamous NSCLC; pemetrexed maintenance; PEM-CIS / PEM-CARB combos
NCCN Clinical Practice Guidelines — Mesothelioma: Pleural
PEM-CIS as 1L standard for malignant pleural mesothelioma
UnitedHealthcare — Oncology Medication Clinical Coverage Policy
Aetna CPB — Pemetrexed (Alimta, Pemfexy)
FDA National Drug Code Directory
Lilly Cares Foundation (Alimta legacy patient assistance)

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 + AMA CPT releases.
NDC, dosing, FDA label, vitamin protocol, renal contraindication, NSAID restriction	Event-driven	Tied to FDA label revision date + multi-generic manufacturer label updates.

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

May 2, 2026 — Initial publication. ASP data: Q2 2026 (J9305 generic NOS). Vitamin supplementation, renal contraindication (CrCl <45 mL/min), NSAID restriction documented per FDA originator label. Three-code disambiguation (J9304 / J9305 / J9322). KEYNOTE-189 combo cross-link to /drugs/keytruda.

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. Vitamin supplementation protocol, renal contraindication, and NSAID restriction are pulled directly from the FDA originator Alimta label (NDA 021462) and apply to all approved pemetrexed products. We do not paraphrase from billing-software vendor blogs.

Pemetrexed (Alimta + generics) — HCPCS J9305

Instant Answer — the 5 things you need to bill J9305

J9305 vs J9304 vs J9322 — pick the right pemetrexed code CMS HCPCS verified May 2026

Dosing & unit math FDA label verified May 2026

Adult dosing — all approved indications

Worked example — standard dose for 1.7 m² BSA patient

Worked example — 2.0 m² BSA patient (no waste scenario)

Combination regimens

Vitamin supplementation protocol — mandatory FDA label verified May 2026

Operational cadence

Billing the supplementation

Renal contraindication — CrCl <45 mL/min FDA label verified May 2026

Renal function workflow

Cockcroft-Gault formula reminder

NSAID restriction — drug interaction FDA label verified May 2026

Patient counseling script

NDC reference FDA NDC Directory verified May 2026

Administration codes CPT verified May 2026

Modifiers CMS verified May 2026

JZ — required when no waste

JW — required when waste occurs (most pemetrexed claims)

JW worked example

Modifier 25 — same-day E/M

340B modifiers (JG, TB)

ICD-10-CM by indication FY2026 verified May 2026

Site of care & place of service Verified May 2026

Claim form field mapping CMS verified May 2026

Payer policy snapshot Reviewed May 2026

Step therapy

Medicare reimbursement CMS Q2 2026 (live)

Q2 2026 payment snapshot — J9305

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Common denials & how to fix them

Frequently asked questions

What is the HCPCS code for pemetrexed?

How many units of J9305 do I bill for a 500 mg/m² dose?

Is vitamin supplementation actually required before pemetrexed?

What is the renal function contraindication for pemetrexed?

What is the NSAID restriction with pemetrexed?

What administration CPT do I use for pemetrexed?

What is the Medicare reimbursement for J9305?

Can I bill J9304 (Alimta) instead of J9305 (NOS) if I dispensed a generic?

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Methodology

Stop calculating pemetrexed waste lines by hand.