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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.

Reviewed Jul 23, 2026 · maintained by Erin Rose · coverage re-verified against CMS quarterly

How Medicare covers physician-administered drugs

For drugs given in a clinic and billed under Medicare Part B, payment turns on the diagnosis. Each Medicare Administrative Contractor (MAC) publishes a Local Coverage Determination (LCD) and a companion Billing & Coding Article listing the exact covered ICD-10 codes for a drug’s J or Q code. Coverage can differ by MAC and change by quarter, so the list you bill against has to be the current article for your state. Every drug below links its covered-diagnosis list, its source article and date, and the ASP+6% reimbursement.

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

Billing units & wastage calculator
Turn a dose into billing units, the JZ/JW split, and the ASP+6% allowed amount.
MAC lookup by state
Find the Medicare contractor that sets Part B coverage where you are.
Self-administered drug (SAD) list
Which drugs Part B excludes and pushes to Part D, by MAC.
Drug billing modifiers
JW / JZ wastage, JA / JB route, and the medical-necessity modifiers.
What changed
Recent moves in covered diagnoses and SAD status, by date.

Coverage policies at a glance

The drugs with a dedicated CMS Billing & Coding Article carry the most detailed, most citable Medicare coverage. The full 40-drug list is in the browser below.

DrugHCPCSCovered ICD-10CMS Article / LCDMAC
Rituximab J9312 Q5115 Q5119 692 A56380 / L35026 Palmetto GBA
Denosumab (Prolia, Xgeva) J0897 434 A52399 / L33394 Wellpoint Federal
Infliximab J1745 Q5103 Q5104 406 A56432 / L35677 Palmetto GBA
Botox (Botulinum Toxin) J0585 J0586 J0587 313 A52848 / L33646 National Government Services, Inc.
Immune Globulin (IVIG) J1459 J1561 J1566 138 A56786 / L35093 Novitas Solutions, Inc.
Eculizumab J1300 Q5140 Q5141 18 A54548 Wellpoint Federal
Omalizumab (Xolair) J2357 17 A52448 / L33394 Wellpoint Federal

Browse all 40 drugs

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 · Wellpoint Federal
Botox (Botulinum Toxin)
J0585 J0586 J0587 J0588
313 covered ICD-10 · A52848 · National Government Services, Inc.
Denosumab (Prolia, Xgeva)
J0897
434 covered ICD-10 · A52399 · Wellpoint Federal
Omalizumab (Xolair)
J2357
17 covered ICD-10 · A52448 · Wellpoint Federal
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

LCD, Billing & Coding Article, or NCD — which one governs?

A Local Coverage Determination (LCD) is your MAC’s policy on whether a drug is reasonable and necessary. The Billing & Coding Article attached to it holds the detail you actually bill against: the exact covered ICD-10 diagnoses and the HCPCS codes they apply to. A National Coverage Determination (NCD), where CMS has issued one, sets a floor that applies in every state. When you check whether a diagnosis is covered, you are reading the Article; the LCD is the policy behind it, and an NCD, if one exists, overrides both.

Why does coverage differ by MAC?

CMS contracts twelve A/B MAC jurisdictions to seven companies, and each sets its own local coverage. The same drug can carry a different covered-diagnosis list under Palmetto than under Novitas. That is why a claim that pays in one state is denied in another, and why the list you rely on must be the article for your MAC. If you are not sure which one governs your practice, start from the MAC lookup.

Frequently asked

How do I find the Medicare-covered diagnoses for a drug?

Open the drug's page here. It lists every covered ICD-10 code from the governing CMS Billing & Coding Article, grouped by condition, with the article ID and its revision date. Confirm the article that applies to your MAC.

Why was my Part B drug claim denied as not medically necessary?

Most often the ICD-10 diagnosis on the claim isn't in the covered list for that J-code, or the article for your MAC differs from the one you checked. Match the diagnosis to the covered list for your state and confirm the documentation supports medical necessity.

Does covered-diagnosis policy differ by state?

Yes. Part B drug coverage is set locally by each MAC, so a diagnosis covered in one jurisdiction may not be covered in another. Use the MAC lookup to find yours.

Is this the same as prior authorization?

No. Covered-diagnosis policy is about whether Medicare pays for a drug-and-diagnosis pairing at all. Prior authorization and step therapy are separate utilization-management requirements this reference does not cover.

Source & how this is maintained

Source
CMS Medicare Coverage Database (Local Coverage Articles and their LCDs) and, where no drug-specific policy exists, FDA-approved labeling. HCPCS J/Q and ICD-10-CM codes are public domain; CPT is AMA-copyrighted and intentionally omitted.
Reviewed
Jul 23, 2026; coverage data re-verified against CMS quarterly.
Maintained by
Erin Rose, Founder, under CareCost’s methodology and editorial policy. Corrections are logged on the Corrections page.
Not advice
General billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.

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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