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Medicare coverage for specialty drugs

Covered ICD-10 diagnoses & Part B reimbursement by drug and J-code · from CMS Local Coverage Articles

Free, dated reference for patient-access and billing staff: which diagnoses Medicare covers for each physician-administered drug, the governing LCD/Article, the contractor (MAC), and the ASP+6% allowed amount. Pick a drug to see its full covered-diagnosis list.

Coverage is set by your MAC and differs by state. Find which Medicare contractor covers you before you rely on a list. Find your MAC by state →

Medicare reference tools: MAC by state · Self-administered drug (SAD) list — Part B vs Part D · Drug billing modifiers (JW/JZ/JA/JB) · What changed

Rituximab
J9312 Q5115 Q5119 Q5123
692 covered ICD-10 · A56380 · Palmetto GBA
Infliximab
J1745 Q5103 Q5104 Q5121
406 covered ICD-10 · A56432 · Palmetto GBA
Immune Globulin (IVIG)
J1459 J1561 J1566 J1568
138 covered ICD-10 · A56786 · Novitas Solutions, Inc.
Eculizumab
J1300 Q5140 Q5141
18 covered ICD-10 · A54548 · National Government Services, Inc.
Botox (Botulinum Toxin)
J0585 J0586 J0587 J0588
313 covered ICD-10 · A52848 · National Government Services, Inc.
Denosumab (Prolia, Xgeva)
J0897
409 covered ICD-10 · A52399 · National Government Services, Inc.
Omalizumab (Xolair)
J2357
17 covered ICD-10 · A52448 · National Government Services, Inc.
Eylea
J0178
75 covered ICD-10 · FDA indications
Opdivo
J9299
44 covered ICD-10 · FDA indications
Injectafer
J1439
8 covered ICD-10 · FDA indications
Venofer
J1756
7 covered ICD-10 · FDA indications
Ocrevus
J2350
10 covered ICD-10 · FDA indications
Vabysmo
J2777
30 covered ICD-10 · FDA indications
Keytruda
J9271
50 covered ICD-10 · FDA indications
Lupron Depot
J1950
11 covered ICD-10 · FDA indications
Entyvio
J3380
10 covered ICD-10 · FDA indications
INFeD
J1750
3 covered ICD-10 · FDA indications
Ocrevus Zunovo
J2351
2 covered ICD-10 · FDA indications
Beovu
J0179
22 covered ICD-10 · FDA indications
Amvuttra
J0225
7 covered ICD-10 · FDA indications
Briumvi
J2329
2 covered ICD-10 · FDA indications
Neulasta
J2506
4 covered ICD-10 · FDA indications
Eylea HD
J0177
47 covered ICD-10 · FDA indications
Trodelvy
J9317
5 covered ICD-10 · FDA indications
Leqembi
J0174
4 covered ICD-10 · FDA indications
Benlysta
J0490
9 covered ICD-10 · FDA indications
Tremfya
J1628
5 covered ICD-10 · FDA indications
Saphnelo
J0491
9 covered ICD-10 · FDA indications
Padcev
J9177
12 covered ICD-10 · FDA indications
Avastin
J9035
13 covered ICD-10 · FDA indications
Bendeka
J9034
5 covered ICD-10 · FDA indications
Nucala
J2182
14 covered ICD-10 · FDA indications
Imfinzi
J9173
11 covered ICD-10 · FDA indications
Vyepti
J3032
13 covered ICD-10 · FDA indications
Humira
J0139
21 covered ICD-10 · FDA indications
Tivdak
J9273
5 covered ICD-10 · FDA indications
Fasenra
J0517
13 covered ICD-10 · FDA indications
Reblozyl
J0896
7 covered ICD-10 · FDA indications
Aranesp
J0881
5 covered ICD-10 · FDA indications
Actemra
J3262
11 covered ICD-10 · FDA indications

How Medicare drug coverage works

For physician-administered drugs billed under Medicare Part B, payment depends on the diagnosis. Each Medicare Administrative Contractor (MAC) publishes a Local Coverage Determination (LCD) stating whether a drug is reasonable and necessary, and a companion Billing & Coding Article that lists the actual covered ICD-10 diagnosis codes and HCPCS codes. A National Coverage Determination (NCD), where one exists, applies nationwide. Coverage can differ by MAC, so always confirm the article that applies in your state. Each drug page here shows the covered diagnoses, the source Article/LCD with its update date, and the ASP+6% reimbursement.

Know what it pays, not just whether it's covered

See Medicare reimbursement and patient out-of-pocket for any specialty drug.

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