Quick answer
J9317
What Medicare pays for Trodelvy (2026 Q4)
2026 Q4 payment limit per billing unit for Trodelvy’s HCPCS code (how ASP + 6% works):
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J9317 | Sacituzumab govitecan-hziy | 2.5 mg | $37.536 |
CMS ASP Drug Pricing File, 2026 Q4. Trodelvy patient out-of-pocket estimate →
Worked billing example for Trodelvy
A concrete, paste-checkable example using J9317’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 800 mg dose — 10 mg/kg IV for an 80 kg reference patient |
| Dose administered | 800 mg |
| Billing unit basis | 1 unit = 2.5 mg |
| Billing units (dose ÷ unit basis, rounded up) | 320 units of J9317 |
| Vial combination drawn (min-waste plan) | 5 × 180 mg vials |
| Discarded (waste) | 100 mg |
| Wastage modifier (JW / JZ) | Bill the 320 administered units on one claim line (no wastage modifier), and the 40 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) | 360 units × $37.536/unit = $13512.96 |
Allowable, not paid: sequestration and the covered diagnosis still apply.
Dose source: drugs/trodelvy.html — "Worked example — 80 kg patient, 800 mg dose". Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Trodelvy (HCPCS J9317) 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 Trodelvy
The 6 FDA-approved indications for J9317, grouped by condition — filter to find a code.
Triple-Negative Breast — 2 diagnoses (applies to J9317)
Neoplasms (2)
| ICD-10 | Covered diagnosis |
|---|---|
| C50.911 | Malignant neoplasm of unspecified site of right female breast |
| C50.919 | Malignant neoplasm of unspecified site of unspecified female breast |
Urothelial Carcinoma — 1 diagnoses (applies to J9317)
Neoplasms (1)
| ICD-10 | Covered diagnosis |
|---|---|
| C67.9 | Malignant neoplasm of bladder, unspecified |
Encounter — 1 diagnoses (applies to J9317)
Factors influencing health status (1)
| ICD-10 | Covered diagnosis |
|---|---|
| Z51.11 | Encounter for antineoplastic chemotherapy |
Breast Cancer — 2 diagnoses (applies to J9317)
Neoplasms (2)
| ICD-10 | Covered diagnosis |
|---|---|
| C50.912 | Malignant neoplasm of unspecified site of left female breast |
| C50.921 | Malignant neoplasm of unspecified site of right male breast |
How to bill Trodelvy
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J9317. Matching codes, units and JZ/JW wastage →
Which policy governs Trodelvy
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 Trodelvy is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J9317, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Trodelvy covered by Medicare?
- Yes. Trodelvy (J9317) 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 J9317 as self-administered.
- What diagnoses are covered for Trodelvy (J9317)?
- Medicare publishes no drug-specific covered-diagnosis list for J9317. The 6 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 Trodelvy?
- No drug-specific LCD or Billing & Coding Article exists for Trodelvy. 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 Trodelvy claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J9317. 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 Trodelvy'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 Trodelvy 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 Trodelvy — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Trodelvy prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Trodelvy”; 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.