Page reviewed Aug 23, 2026 · from CMS Article A54548 (CMS last revised 09/17/2025)
Quick answer
Medicare benefit
Part B (physician-administered)
Covered diagnoses
18 ICD-10 codes
Governing policy
A54548
Contractor (MAC)
Wellpoint Federal
CMS article revised
09/17/2025
Page reviewed
Aug 23, 2026
HCPCS codes covered:
J1299Q5151Q5152
J1299Q5151Q5152
Coverage varies by Medicare Administrative Contractor (MAC). This list is Wellpoint Federal's policy (Article A54548). In another state? Other MACs may publish a different covered list — find your MAC by state →
What Medicare pays for Eculizumab (2026 Q4)
2026 Q4 payment limit per billing unit for Eculizumab’s HCPCS codes (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J1299 | Inj, eculizumab, 2 mg | 2 mg | $43.763 |
| Q5151 | Inj, eculizumab-aagh, 2 mg | 2 mg | $31.547 |
| Q5152 | Inj, eculizumab-aeeb, 2 mg | 2 mg | $40.412 |
CMS ASP Drug Pricing File, 2026 Q4. Eculizumab patient out-of-pocket estimate →
Eculizumab (HCPCS J1299, Q5151, Q5152) is paid under Part B only when the claim’s ICD-10 code is one Wellpoint Federal lists in Article A54548; otherwise expect a CO-50 denial. How Part B drug coverage is decided →
Covered ICD-10 diagnoses for Eculizumab
The 18 codes below are the diagnoses Wellpoint Federal accepts for J1299 under Article A54548, grouped exactly as CMS groups them and organized by condition category for scanning. Use the filter in each group to find a specific code or condition.
Group 1 — 18 covered diagnoses
Diseases of the genitourinary system (10)
| ICD-10 | Covered diagnosis |
|---|---|
| N00.6 | Acute nephritic syndrome with dense deposit disease |
| N00.B1 | Acute nephritic syndrome with idiopathic immune membranoproliferative glomerulonephritis (IC-MPGN) |
| N00.B2 | Acute nephritic syndrome with secondary immune complex membranoproliferative glomerulonephritis (IC-MPGN) |
| N01.6 | Rapidly progressive nephritic syndrome with dense deposit disease |
| N02.6 | Recurrent and persistent hematuria with dense deposit disease |
| N03.6 | Chronic nephritic syndrome with dense deposit disease |
| N04.6 | Nephrotic syndrome with dense deposit disease |
| N04.B1 | Nephrotic syndrome with idiopathic immune complex membranoproliferative glomerulonephritis (IC-MPGN) |
| N04.B2 | Nephrotic syndrome with secondary immune complex membranoproliferative glomerulonephritis (IC-MPGN) |
| N07.6 | Hereditary nephropathy, not elsewhere classified with dense deposit disease |
Blood, blood-forming organs & immune disorders (4)
| ICD-10 | Covered diagnosis |
|---|---|
| D59.31 | Infection-associated hemolytic-uremic syndrome |
| D59.32 | Hereditary hemolytic-uremic syndrome |
| D59.39 | Other hemolytic-uremic syndrome |
| D59.5 | Paroxysmal nocturnal hemoglobinuria [Marchiafava-Micheli] |
Diseases of the nervous system (3)
| ICD-10 | Covered diagnosis |
|---|---|
| G36.0 | Neuromyelitis optica [Devic] |
| G70.00 | Myasthenia gravis without (acute) exacerbation |
| G70.01 | Myasthenia gravis with (acute) exacerbation |
Injury, poisoning & external causes (1)
| ICD-10 | Covered diagnosis |
|---|---|
| T86.19 | Other complication of kidney transplant |
What commercial payers require for Eculizumab
Medicare Part B is only half the answer — most Eculizumab claims are adjudicated by a commercial plan with its own medical policy. Below is what 29 commercial payers publish for Eculizumab, read from each payer's own policy document. 27 of 27 that state a position require prior authorization (2 do not say clearly, so confirm those on the call), and 16 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 15 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 Utilization Management Policy applies; see referenced policy for infusion site requirements | 4 | 2026-03-31 |
| Anthem / Elevance policy ↗ | Required | — | — | 4 | 2024-02-23 |
| Arkansas BCBS policy ↗ | Required | J1299, Q5151, Q5152 | — | 4 | 2026-01-01 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 4 | 2025-10-01 |
| BCBS Kansas policy ↗ | Not stated — confirm on the call | — | Site-of-care program applies | 4 | — |
| BCBS Louisiana policy ↗ | Required | — | — | 4 | 2025-11-01 |
| BCBS Massachusetts policy ↗ | Required | — | — | 4 | 2026-03-15 |
| BCBS Michigan policy ↗ | Required | Q5152 | Site-of-care program applies | 4 | 2025-10-09 |
| BCBS Minnesota policy ↗ | Required | — | — | 4 | 2025-09-04 |
| BCBS Mississippi policy ↗ | Required | Q5151 | — | 4 | 2026-08-15 |
| BCBS Nebraska policy ↗ | Required | Q5151 | — | 4 | 2025-11-05 |
| BCBS South Carolina policy ↗ | Unclear — confirm on the call | Q5151 | Site-of-care program applies | 4 | — |
| BCBS Tennessee policy ↗ | Required | Q5152, Q5151 | — | 4 | 2026-01-13 |
| Blue Shield of California policy ↗ | Required | Q5151 | Hospital outpatient facility requires specific criteria including new therapy initiation, re-initiation, or clinical instability; hospital_outpatient | 4 | 2026-05-01 |
| Capital BlueCross policy ↗ | Required | Q5151, Q5152 | — | 4 | 2025-09-04 |
| CareFirst BCBS policy ↗ | Required | — | outpatient_hospital | 4 | — |
| Centene / Ambetter policy ↗ | Required | — | — | 4 | 2026-01-01 |
| Cigna policy ↗ | Required | — | Site-of-care program applies | 4 | 2025-10-01 |
| Excellus BCBS policy ↗ | Required | Q5151 | Site-of-care program applies | 4 | 2026-07-01 |
| Florida Blue policy ↗ | Required | Q5151 | hospital_affiliated_outpatient_additional_requirements; 09-J3000-46 | 4 | 2026-07-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Required | — | Site-of-care program applies | 4 | 2025-02-15 |
| Highmark BCBS policy ↗ | Required | J1299 | Site-of-care program applies | 4 | 2026-03-01 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | — | 4 | 2025-12-19 |
| Horizon BCBS NJ policy ↗ | Required | — | Site of administration governed by separate Policy #142 (Site of Administration for Infusion and Injectable Prescription Medications) | 4 | 2020-09-11 |
| Independence Blue Cross policy ↗ | Required | Q5151 | most appropriate and cost-effective setting | 4 | 2026-01-01 |
| Premera Blue Cross policy ↗ | Required | — | These are the preferred medically necessary sites of service for specified drugs. | 4 | 2026-06-01 |
| Regence BCBS policy ↗ | Required | Q5151 | site-of-care administration requirements apply per dru408 | 4 | 2026-05-01 |
| UnitedHealthcare policy ↗ | Required | Q5151, Q5152 | Site-of-care program applies | 4 | 2026-08-01 |
| Wellmark BCBS policy ↗ | Required | Q5151 | — | 4 | 2026-01-01 |
What Eculizumab payers put in writing
Quoted from the medical policies linked above — 24 distinct requirements across 29 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
18 years of age or older
— BCBS Federal Employee Program, BCBS Kansas and 3 other payers policy ↗The requested medication will not be used in combination with another complement inhibitor (e.g., Empaveli, Fabhalta, PiaSky, Ultomiris) for the treatment of PNH
— Aetna, HMSA (BCBS Hawaii), Wellmark BCBS policy ↗Hemoglobin that is less than or equal to 7 g/dl, or the individual has symptoms of anemia, and the hemoglobin is less than or equal to 9 g/dl
— Arkansas BCBS, BCBS Kansas, BCBS South Carolina policy ↗Myasthenia Gravis Foundation of America (MGFA) clinical classification II to IV
— BCBS Tennessee, CareFirst BCBS, HMSA (BCBS Hawaii) policy ↗Prescribed by or in consultation with a hematologist or nephrologist
— Blue Shield of California, Centene / Ambetter, UnitedHealthcare policy ↗Member has had an inadequate response or intolerable adverse event to at least two immunosuppressive therapies over the course of at least 12 months
— Aetna, HMSA (BCBS Hawaii) policy ↗
Prior authorization
Submission of the following information is necessary to initiate the prior authorization review
— BCBS Tennessee, CareFirst BCBS, Wellmark BCBS policy ↗Prior authorization validity will be provided initially for 6 months.
— BCBS Minnesota, Capital BlueCross policy ↗Precertification of eculizumab (Soliris), eculizumab-aeeb (Bkemv), or eculizumab-aagh (Epysqli) is required of all Aetna participating providers
— Aetna policy ↗Effective April 01, 2018, prior approval is required for Eculizumab (e.g., Soliris).
— Arkansas BCBS policy ↗Prior authorization is required to ensure the safe, clinically appropriate, and cost-effective use of Soliris and its biosimilars
— BCBS Federal Employee Program policy ↗Initiation of eculizumab or biosimilars (Soliris, Epysqli, Bkemv) meets the definition of medical necessity when the following are met
— Florida Blue policy ↗
Quantity and frequency limits
Soliris 300 mg/30 mL vial* 8 vials per 28 days
— Anthem / Elevance policy ↗Greater than or equal to 40 kg: 900 mg weekly for the first 4 weeks, followed by 1200 mg for the fifth dose
— Florida Blue policy ↗Dose does not exceed 900 mg every 2 weeks after a loading dose of 600 mg weekly for 4 weeks
— BCBS Louisiana policy ↗Dose does not exceed 1,200 mg every 2 weeks after a loading dose of 900 mg weekly for 4 weeks
— BCBS Louisiana policy ↗900 mg intravenously every 14 days
— BCBS Minnesota policy ↗1200 mg intravenously every 14 days
— BCBS Minnesota policy ↗
Dosing rules
900 mg for the 5th dose 7 days later, then every 14 days thereafter.
— BCBS Kansas policy ↗1200 mg for the 5th dose 1 week later, then every 2 weeks thereafter.
— BCBS Kansas policy ↗1,200 mg every 2 weeks thereafter.
— BCBS Kansas policy ↗Maintenance: Up to 1,200 mg at week 5, then up to 1,200 mg every 2 weeks thereafter
— BCBS Kansas policy ↗Initial: 900mg weekly for 4 doses Maintenance: 1200mg every 2 weeks, starting
— BCBS Tennessee policy ↗Dose does not exceed 600 mg per week for the first 4 weeks, followed by 900 mg for the fifth dose 1 week later, then 900 mg every 2 weeks thereafter.
— Centene / Ambetter 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 Eculizumab
Put the patient's covered ICD-10 diagnosis on the claim line with J1299. Matching codes, units and JZ/JW wastage →
Which policy governs Eculizumab
The covered code lists live in Article A54548 — CMS moved code lists out of LCDs and into Articles, which is why the diagnoses live in the Article. What an LCD, an Article and an NCD each govern →
If a claim for Eculizumab is denied
The usual cause is a diagnosis outside Article A54548's covered list, or a product code and unit count that do not match what was given. The five denial patterns and how to fix each →
Frequently asked questions
- Is Eculizumab covered by Medicare?
- Yes. Eculizumab (J1299) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary, covered diagnosis. Local coverage is defined by Wellpoint Federal in Billing & Coding Article A54548. None of the 8 Medicare Administrative Contractors lists these codes as self-administered.
- What diagnoses are covered for Eculizumab (J1299)?
- Medicare lists 18 covered ICD-10 diagnosis codes for J1299 under Article A54548. The full list is on this page, grouped by condition category. Coverage can vary by Medicare Administrative Contractor (MAC); confirm against the article that applies in your state.
- Which Medicare policy covers Eculizumab?
- Billing & Coding Article A54548 (v36), published by Wellpoint Federal and last updated 09/17/2025.
- Why was my Eculizumab claim denied as not medically necessary?
- The most common cause is an ICD-10 diagnosis on the claim that is not in the covered list for J1299. Confirm the patient's diagnosis is in the groups below, that documentation supports medical necessity, and that you are using the article for 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 Eculizumab'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 Eculizumab cost & patient owe →Source & verification
- Source
- CMS Medicare Coverage Database — Billing & Coding Article A54548 (v36) — Wellpoint Federal.
- Primary sources
- DailyMed — Eculizumab prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — Article A54548
- CMS article last revised
- 09/17/2025
- 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.