Quick answer
J0896
What Medicare pays for Reblozyl (2026 Q4)
2026 Q4 payment limit per billing unit for Reblozyl’s HCPCS code (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J0896 | Inj luspatercept-aamt 0.25mg | 0.25 mg | $43.484 |
CMS ASP Drug Pricing File, 2026 Q4. Reblozyl patient out-of-pocket estimate →
Worked billing example for Reblozyl
A concrete, paste-checkable example using J0896’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 70 mg starting dose — 1 mg/kg SC q3wk for a 70 kg reference patient |
| Dose administered | 70 mg |
| Billing unit basis | 1 unit = 0.25 mg |
| Billing units (dose ÷ unit basis, rounded up) | 280 units of J0896 |
| Vial combination drawn (min-waste plan) | 1 × 75 mg vial |
| Discarded (waste) | 5 mg |
| Wastage modifier (JW / JZ) | Bill the 280 administered units on one claim line (no wastage modifier), and the 20 discarded units on a separate line with JW. Do not add JZ — JW and JZ are never billed together for the same drug on the same date of service. JW vs JZ, with examples → |
| Medicare allowable (ASP + 6%, 2026 Q4) | 300 units × $43.484/unit = $13045.20 |
Allowable, not paid: sequestration and the covered diagnosis still apply.
Dose source: drugs/reblozyl.html — FAQ: "a 70 kg patient receiving 1 mg/kg (70 mg) is billed as 280 units.". Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Reblozyl (HCPCS J0896) 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 Reblozyl
The 9 FDA-approved indications for J0896, grouped by condition — filter to find a code.
MDS-associated Anemia — 1 diagnoses (applies to J0896)
Neoplasms (1)
| ICD-10 | Covered diagnosis |
|---|---|
| D46.9 | Myelodysplastic syndrome, unspecified |
Beta Thalassemia — 1 diagnoses (applies to J0896)
Blood, blood-forming organs & immune disorders (1)
| ICD-10 | Covered diagnosis |
|---|---|
| D56.1 | Beta thalassemia |
Anemia — 1 diagnoses (applies to J0896)
Blood, blood-forming organs & immune disorders (1)
| ICD-10 | Covered diagnosis |
|---|---|
| D63.0 | Anemia in neoplastic disease |
MDS — 6 diagnoses (applies to J0896)
Neoplasms (6)
| ICD-10 | Covered diagnosis |
|---|---|
| D46.0 | Refractory anemia without ring sideroblasts |
| D46.1 | Refractory anemia with ring sideroblasts |
| D46.20 | Refractory anemia with excess of blasts, unspecified |
| D46.21 | Refractory anemia with excess of blasts 1 |
| D46.22 | Refractory anemia with excess of blasts 2 |
| D46.4 | Refractory anemia, unspecified |
What commercial payers require for Reblozyl
Medicare Part B is only half the answer — most Reblozyl claims are adjudicated by a commercial plan with its own medical policy. Below is what 27 commercial payers publish for Reblozyl, read from each payer's own policy document. 23 of 23 that state a position require prior authorization (4 do not say clearly, so confirm those on the call), and 5 run a site-of-care program that can push the infusion out of the hospital outpatient setting.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | — | 2 | 2026-06-12 |
| Anthem / Elevance policy ↗ | Required | — | — | 3 | 2022-09-19 |
| Arkansas BCBS policy ↗ | Required | — | — | 2 | 2026-06-01 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 3 | 2026-07-01 |
| BCBS Kansas policy ↗ | Required | — | Site-of-care program applies | 3 | 2026-04-01 |
| BCBS Louisiana policy ↗ | Unclear — confirm on the call | — | — | 3 | 2026-01-01 |
| BCBS Massachusetts policy ↗ | Required | — | — | 3 | — |
| BCBS Michigan policy ↗ | Required | — | Site-of-care program applies | 3 | 2025-10-09 |
| BCBS Minnesota policy ↗ | Required | — | — | 3 | 2026-04-01 |
| BCBS Mississippi policy ↗ | Required | — | — | 3 | 2026-05-26 |
| BCBS Nebraska policy ↗ | Required | — | — | 1 | 2025-11-05 |
| BCBS South Carolina policy ↗ | Required | — | Site-of-care program applies | — | 2026-01-01 |
| BCBS Tennessee policy ↗ | Required | — | — | 3 | 2026-06-30 |
| Blue Shield of California policy ↗ | Required | — | — | 1 | 2026-05-01 |
| Capital BlueCross policy ↗ | Required | — | — | 3 | 2026-04-01 |
| CareFirst BCBS policy ↗ | Required | — | — | 3 | — |
| Centene / Ambetter policy ↗ | Required | — | — | 3 | 2026-01-01 |
| Cigna policy ↗ | Required | — | Site-of-care program applies | 3 | 2026-04-01 |
| Excellus BCBS policy ↗ | Required | — | — | 3 | 2026-07-29 |
| Florida Blue policy ↗ | Required | — | — | 2 | 2026-07-01 |
| Highmark BCBS policy ↗ | Not stated — confirm on the call | — | — | 1 | 2026-05-01 |
| Horizon BCBS NJ policy ↗ | Not stated — confirm on the call | — | — | 1 | 2020-06-09 |
| Independence Blue Cross policy ↗ | Not stated — confirm on the call | — | reimbursement limited to the most appropriate, cost-effective setting | 3 | 2026-03-23 |
| Premera Blue Cross policy ↗ | Required | — | — | 1 | 2026-05-01 |
| Regence BCBS policy ↗ | Required | — | — | 2 | 2026-06-04 |
| UnitedHealthcare policy ↗ | Required | — | — | 3 | 2026-08-01 |
| Wellmark BCBS policy ↗ | Required | — | — | 3 | 2026-06-03 |
What Reblozyl 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
Anemia of myelodysplastic syndrome or myelodysplastic/myeloproliferative neoplasm and myelofibrosis-associated anemia: a hematologist or oncologist.
— Aetna, CareFirst BCBS policy ↗Individual is 18 years of age or older
— Anthem / Elevance, Highmark BCBS policy ↗Used following no response* to or relapse after imetelstat
— BCBS Kansas, BCBS Minnesota policy ↗Authorization of 16 weeks may be granted for treatment of anemia with beta thalassemia in members 18 years of age or older
— CareFirst BCBS, Wellmark BCBS policy ↗The member has symptomatic anemia evidenced by a pretreatment or pretransfusion Hgb level less than or equal to 11 grams per deciliter (g/dL).
— CareFirst BCBS, Wellmark BCBS policy ↗Anemia with beta thalassemia: hematologist or specialist in the treatment of beta thalassemia
— Aetna policy ↗
Prior authorization
Precertification of luspatercept-aamt (Reblozyl) is required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization)
— Anthem / Elevance policy ↗Effective June 1, 2020, Prior Approval is required for Luspatercept-aamt (e.g., Reblozyl).
— Arkansas BCBS policy ↗Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of Reblozyl while maintaining optimal therapeutic outcomes.
— BCBS Federal Employee Program policy ↗Initiation of luspatercept-aamt (Reblozyl) meets the definition of medical necessity when ANY of the following criteria are met
— Florida Blue policy ↗Line of Business PA Required in Medical Management System (Yes/No) BCBS Yes BCN Yes MAPPO Yes BCNA Yes
— BCBS Michigan policy ↗
Quantity and frequency limits
Beta Thalassemia: 600 billable units every 21 days
— BCBS Kansas, BCBS Minnesota, Capital BlueCross policy ↗Myelodysplastic Syndromes and Myeloproliferative Neoplasms: 800 billable units every 21 days
— BCBS Kansas, BCBS Minnesota, Capital BlueCross policy ↗Authorization of 24 weeks may be granted for treatment of anemia of myelodysplastic syndrome or myelodysplastic/myeloproliferative neoplasm in members 18 years of age or older when all of the following criteria are met
— BCBS Tennessee, CareFirst BCBS policy ↗Prior - Approval Limits Duration 6 months
— BCBS Federal Employee Program policy ↗Dosage of luspatercept-aamt does not exceed 1 mg/kg every 3 weeks for the first two doses, 1.33 mg/kg every 3 weeks for the next two doses, and then 1.75 mg/kg every 3 weeks for subsequent doses
— Florida Blue policy ↗Dose will not exceed 1.25 mg/kg every 3 weeks for beta thalassemia or 1.75 mg/kg
— BCBS Louisiana policy ↗
Dosing rules
The recommended starting dose is 1 mg/kg once every 3 weeks by subcutaneous injection.
— Aetna policy ↗Dose will not exceed 1.25 mg/kg every 3 weeks
— BCBS Louisiana policy ↗Dose will not exceed 1.75 mg/kg every 3 weeks
— BCBS Louisiana policy ↗1 mg/kg SC once every 3 weeks
— Centene / Ambetter policy ↗Initial: 1 mg/kg SC once every 3 weeks
— Centene / Ambetter policy ↗1 mg/kg dosing; c. New dose does not exceed 1.75 mg/kg every 3 weeks, and documentation
— 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 Reblozyl
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J0896. Matching codes, units and JZ/JW wastage →
Which policy governs Reblozyl
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 Reblozyl is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J0896, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Reblozyl covered by Medicare?
- Yes. Reblozyl (J0896) 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 J0896 as self-administered.
- What diagnoses are covered for Reblozyl (J0896)?
- Medicare publishes no drug-specific covered-diagnosis list for J0896. The 9 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 Reblozyl?
- No drug-specific LCD or Billing & Coding Article exists for Reblozyl. 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 Reblozyl claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J0896. 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 Reblozyl'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 Reblozyl 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 Reblozyl — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Reblozyl prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Reblozyl”; 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.