Quick answer
J0225
What Medicare pays for Amvuttra (2026 Q4)
2026 Q4 payment limit per billing unit for Amvuttra’s HCPCS code (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0225 | Inj, vutrisiran, 1 mg | 1 mg | $5008.939 |
CMS ASP Drug Pricing File, 2026 Q4. Amvuttra patient out-of-pocket estimate →
Worked billing example for Amvuttra
A concrete, paste-checkable example using J0225’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 25 mg fixed SC dose, every 3 months |
| Dose administered | 25 mg |
| Billing unit basis | 1 unit = 1 mg |
| Billing units (dose ÷ unit basis, rounded up) | 25 units of J0225 |
| Vial combination drawn (min-waste plan) | 1 × 25 mg vial |
| Discarded (waste) | None |
| Wastage modifier (JW / JZ) | Bill all 25 units on a single line with JZ (attests zero drug discarded). JW vs JZ, with examples → |
| Medicare allowable (ASP + 6%, 2026 Q4) | 25 units × $5008.939/unit = $125223.48 |
Allowable, not paid: sequestration and the covered diagnosis still apply.
Dose source: drugs/amvuttra.html — "Standard dose: 25 mg SC q3mo ... fixed dose, NOT weight-based". Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Amvuttra (HCPCS J0225) is paid under Part B only when the claim’s ICD-10 code is one the MAC accepts; otherwise expect a CO-50 denial. How Part B drug coverage is decided →
Covered ICD-10 diagnoses for Amvuttra
The 7 FDA-approved indications for J0225, grouped by condition — filter to find a code.
hATTR Amyloidosis — 5 diagnoses (applies to J0225)
Endocrine, nutritional & metabolic diseases (4)
| ICD-10 | Covered diagnosis |
|---|---|
| E85.1 | Neuropathic heredofamilial amyloidosis |
| E85.2 | Heredofamilial amyloidosis, unspecified |
| E85.4 | Organ-limited amyloidosis |
| E85.89 | Other amyloidosis |
Diseases of the nervous system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| G63 | Polyneuropathy in diseases classified elsewhere |
Amyloidosis — 2 diagnoses (applies to J0225)
Endocrine, nutritional & metabolic diseases (2)
| ICD-10 | Covered diagnosis |
|---|---|
| E85.81 | Light chain (AL) amyloidosis |
| E85.82 | Wild-type transthyretin-related (ATTR) amyloidosis |
What commercial payers require for Amvuttra
Medicare Part B is only half the answer — most Amvuttra claims are adjudicated by a commercial plan with its own medical policy. Below is what 27 commercial payers publish for Amvuttra, read from each payer's own policy document. 18 of 18 that state a position require prior authorization (9 do not say clearly, so confirm those on the call), and 9 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 1 name a preferred product you must try or fail first.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | Site-of-care program applies | 2 | 2026-03-13 |
| Anthem / Elevance policy ↗ | Required | — | — | 1 | 2024-09-23 |
| Arkansas BCBS policy ↗ | Required | — | — | 2 | 2022-11-09 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 2 | 2026-04-01 |
| BCBS Kansas policy ↗ | Required | — | — | 2 | 2025-05-05 |
| BCBS Louisiana policy ↗ | Unclear — confirm on the call | — | — | 2 | 2026-08-01 |
| BCBS Massachusetts policy ↗ | Required | — | — | 2 | 2026-03-15 |
| BCBS Michigan policy ↗ | Required | — | — | 2 | 2026-07-27 |
| BCBS Minnesota policy ↗ | Required | — | — | 2 | 2025-05-05 |
| BCBS South Carolina policy ↗ | Unclear — confirm on the call | — | — | 2 | — |
| BCBS Tennessee policy ↗ | Required | — | — | 2 | 2026-01-30 |
| Blue Shield of California policy ↗ | Required | — | Site-of-care program applies | 2 | 2026-07-01 |
| Capital BlueCross policy ↗ | Required | — | — | 2 | 2025-05-05 |
| CareFirst BCBS policy ↗ | Required | J0225 | Site-of-care program applies | 2 | — |
| Centene / Ambetter policy ↗ | Unclear — confirm on the call | — | — | 1 | 2022-06-13 |
| Cigna policy ↗ | Required | — | — | 2 | 2026-04-15 |
| Excellus BCBS policy ↗ | Unclear — confirm on the call | — | Site-of-care program applies | 2 | 2026-07-01 |
| Florida Blue policy ↗ | Unclear — confirm on the call | — | — | 2 | 2026-07-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Required | — | Site-of-care program applies | 1 | 2024-07-15 |
| Highmark BCBS policy ↗ | Unclear — confirm on the call | — | Site-of-care program applies | 2 | 2026-02-23 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | — | 2 | 2026-04-01 |
| Horizon BCBS NJ policy ↗ | Required | — | — | 2 | 2025-05-05 |
| Independence Blue Cross policy ↗ | Not stated — confirm on the call | — | — | 2 | 2025-08-18 |
| Premera Blue Cross policy ↗ | Unclear — confirm on the call | — | Site-of-care program applies | 2 | — |
| Regence BCBS policy ↗ | Required | — | Site-of-care program applies | 2 | 2026-06-01 |
| UnitedHealthcare policy ↗ | Not stated — confirm on the call | — | Amvuttra is on UnitedHealthcare's Provider Administered Drugs – Site of Care list (updated 10/01/2026). An infusion in a hospital outpatient department (place of service 19 or 22) has to meet that policy's criteria; a physician office, home infusion or ambulatory infusion suite is an accepted alternative. | 2 | 2026-06-01 |
| Wellmark BCBS policy ↗ | Required | — | — | 2 | 2026-03-06 |
What Amvuttra payers put in writing
Quoted from the medical policies linked above — 24 distinct requirements across 27 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
This medication must be prescribed by or in consultation with a neurologist, geneticist, cardiologist, or physician specializing in the treatment of amyloidosis.
— Aetna, BCBS Tennessee, CareFirst BCBS policy ↗Member is 18 years of age or older.
— BCBS Tennessee, Excellus BCBS, Wellmark BCBS policy ↗Patient has not been the recipient of an orthotopic liver transplant (OLT)
— BCBS Kansas, BCBS Minnesota policy ↗Patient has a baseline 6-minute walk-test (6MWT) distance of ≥150 meters
— BCBS Kansas, BCBS Minnesota policy ↗Prescribed by all relevant specialties or in consultation with physicians experienced in the treatment of ATTR amyloidosis (e.g. a board certified or board-eligible cardiologist, neurologist).
— BCBS Massachusetts, BCBS South Carolina policy ↗Prescribed by or in consultation with a neurologist or physician who specializes in the treatment of amyloidosis Diagnosis of polyneuropathy associated with her
— BCBS South Carolina, Highmark BCBS policy ↗
Prior authorization
Submission of supporting clinical documentation (including but not limited to medical records, chart notes, lab results, and confirmatory diagnostics) related to the medical necessity criteria is REQUIRED on all requests for authorizations.
— BCBS Kansas, Capital BlueCross policy ↗Precertification of patisiran (Onpattro), eplontersen (Wainua), inotersen (Tegsedi), and vutrisiran (Amvuttra) are required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗Prior approval is required for Patisiran (e.g., Onpattro).
— Arkansas BCBS policy ↗Prior authorization is required to ensure the safe, clinically appropriate, and cost-effective use of Amvuttra while maintaining optimal therapeutic outcomes.
— BCBS Federal Employee Program policy ↗J0225 Infusion Site of Care, Provider Administered Drug Therapy Injection, vutrisiran, 1 mg BCBSTX
— HCSC (IL/TX/OK/NM/MT) policy ↗All requests must meet the Prior Authorization requirement.
— BCBS Massachusetts policy ↗
Quantity and frequency limits
25 billable units (25 mg) every 3 months
— BCBS Kansas, BCBS Minnesota, Capital BlueCross policy ↗1 pre-filled syringe per 90 days
— BCBS Federal Employee Program policy ↗Quantity Limits: Align with FDA recommended dosing
— BCBS Michigan policy ↗The recommended dosage is 25 mg every 3 months
— BCBS South Carolina policy ↗Dose does not exceed 25 mg every 3 months.
— Centene / Ambetter policy ↗Quantity Limit: 1 syringe per 84 days
— Excellus BCBS policy ↗
Dosing rules
The recommended dosage of Amvuttra is 25 mg administered by subcutaneous injection once every 3 months.
— Aetna policy ↗Amvuttra (vutrisiran) 25 mg/0.5 mL syringe 1 syringe per 3 months
— Anthem / Elevance policy ↗Dose does not exceed 25 mg every 3 months
— Florida Blue policy ↗Dose will not exceed 25 mg every 3 months.
— BCBS Louisiana policy ↗Up to 25 mg given subcutaneously once every 3 months
— Blue Shield of California policy ↗F. Amvuttra will be administered as a 25mg dose every 3 months
— CareFirst BCBS policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Amvuttra
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J0225. Matching codes, units and JZ/JW wastage →
Which policy governs Amvuttra
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Amvuttra is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J0225, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Amvuttra covered by Medicare?
- Yes. Amvuttra (J0225) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point. None of the 8 Medicare Administrative Contractors lists J0225 as self-administered.
- What diagnoses are covered for Amvuttra (J0225)?
- Medicare publishes no drug-specific covered-diagnosis list for J0225. The 7 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Amvuttra?
- No drug-specific LCD or Billing & Coding Article exists for Amvuttra. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Amvuttra claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J0225. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Amvuttra's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Amvuttra cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Amvuttra — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Amvuttra prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Amvuttra”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-09-21; we re-verify against CMS quarterly).
- Notes
- ICD-10-CM is public domain; CPT® (AMA) is intentionally not listed. Reference, not billing advice — built from the CMS Coverage API per our methodology; corrections to editorial@carecostestimate.com.