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J0222

PAYER POLICY CHANGES

J0222 Insurance Policy Changes

HCPCS J0222 is officially defined as "Injection, patisiran, 0.1 mg." HCPCS J0222 is referenced in 8 tracked payer policy changes from Florida Blue, Arkansas Blue Cross Blue Shield, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J0222 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Florida Blue · Effective Jul 1, 2026High impact
Site of Care Guidelines Expansion: Select Oncology and Non-Oncology Provider-Administered Medications
Effective July 1, 2026, if a Florida Blue member does not meet the Site of Care criteria for administration at an outpatient hospital facility, an alternative site of care will be required for select oncology immunotherapies used as monotherapy and select non-oncology provider-administered medications. The change applies to new prior authorization requests under the listed Small Group ACA, Individual Under 65 ACA and Large Group Fully Insured products, while members receiving these medications at home, an independent ambulatory infusion center or a professional office are not impacted, and pediatric patients under 18 and patients receiving oncology immunotherapy with chemotherapy are excluded. After a current authorization expires, outpatient hospital administration is covered only when one of the listed criteria is met, and Prime MPS allows one-time temporary authorizations, most often 60 days, at outpatient hospital facilities during the transition.
Florida Blue · Effective Jun 1, 2026High impact
New Drug Waste Reduction Guideline
Florida Blue, in collaboration with Prime Therapeutics Medical Pharmacy Solutions, began a Drug Waste Reduction Guideline for select provider-administered medications on June 1, 2026. Under the guideline, the medication dose must align to the most efficient vial size combination when clinically appropriate, and it applies to all Florida Blue and Truli for Health commercial plans. For prior authorization requests on listed medications, the optimized dose cannot be bypassed, and the request moves to pending status for additional clinical review.
Arkansas Blue Cross Blue Shield · Effective Feb 1, 2026Medium impact
Policy Criteria Change
Arkansas Blue Cross updated coverage criteria for several medications effective 2/1/2026, including archiving Beremagene Geperpavec-svdt and moving it to self-administered medication policy, expanding Pertuzumab coverage to include age 18+ patients and new off-label indications, updating maximum dosage quantities for medical benefit drugs, and adding two new policies for advanced Parkinson's disease and multiple myeloma treatments.
Independence Blue Cross · Effective Aug 18, 2025Medium impact
MA08.100e, patisiran (Onpattro®) and vutrisiran (Amvuttra®)
Independence Blue Cross Medicare Advantage policy MA08.100e was updated on 08/18/2025 to add coverage criteria for vutrisiran (Amvuttra) for treatment of Wild-Type or Hereditary Transthyretin Amyloidosis with Cardiomyopathy (ATTR-CM) in adults. ICD-10 diagnosis codes were removed from the policy as informational only; providers must report the most appropriate diagnosis code supporting medical necessity. The policy continues to cover both patisiran (Onpattro) and vutrisiran (Amvuttra) for hATTR amyloidosis with polyneuropathy.
Independence Blue Cross · Effective Aug 18, 2025Medium impact
08.01.50e, Patisiran (Onpattro®) and vutrisiran (Amvuttra®)
Independence Blue Cross updated policy 08.01.50e to add coverage criteria for vutrisiran (Amvuttra) for treatment of wild-type or hereditary transthyretin amyloidosis with cardiomyopathy (ATTR-CM) in adults. The policy now covers both patisiran (Onpattro) and vutrisiran for polyneuropathy and cardiomyopathy indications. All ICD-10 codes were removed as informational; billing teams must report appropriate diagnosis codes supporting medical necessity criteria outlined in the policy.
Mississippi Medicaid (DOM) · Effective Jul 1, 2025Medium impact
Physician Administered Drugs: Prior Authorization Requirements
Effective July 1, 2025, Mississippi Medicaid will require prior authorization for 10 new physician-administered drugs (PADs) including aflibercept, olanzapine long-acting, risperidone, inclisiran, vutrisiran, patisiran, eptinezumab, viltolarsen, tezepelumab, and crizanlizumab. Additionally, pemetrexed (J9305) will no longer require prior authorization. Telligen handles all authorization requests for FFS Medicaid beneficiaries.
Aetna · Identified Aug 18, 2026Medium impact
Transthyretin-Mediated (ATTR) Amyloidosis (CPB 0939, reviewed 2026-08-10)
Aetna's commercial Clinical Policy Bulletin 0939 covers patisiran (Onpattro), eplontersen (Wainua) and vutrisiran (Amvuttra) for polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis, and covers vutrisiran (Amvuttra) for cardiomyopathy of wild-type or hereditary transthyretin-mediated amyloidosis (ATTR-CM) in adults. Precertification is required for patisiran, eplontersen and vutrisiran in applicable plan designs. For the polyneuropathy indications, the diagnosis must be confirmed by detection of a pathogenic variant in the TTR gene. The policy states that each of these products may not be used in combination with the other listed ATTR products, and that concurrent use of patisiran with eplontersen and/or vutrisiran is experimental, investigational or unproven.
Premera Blue Cross · Identified Jun 18, 2026Medium impact
Medical Policy and Coding Updates - October 2019
This medical policy and coding update for WA and Alaska lists changes with effective dates from September 1, 2019 through January 3, 2020. Several medical policies state that a service may be considered medically necessary when criteria are met, while others are considered investigational, including irreversible electroporation (NanoKnife System) and implantable peripheral nerve stimulation for chronic pain. Coding updates effective October 1, 2019 add codes that now require review for medical necessity and prior authorization, including J1303, J9204, J0593, J9118 and Q5116.

Watch J0222

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REFERENCE DATA

Payers with rules19

Payers requiring prior auth19

Aetna · Effective November 1, 2026
Prior authorization required
Participating provider precertification list for Aetna
Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
Fidelis Care · Effective November 1, 2026
Prior authorization required
Fidelis Care Metal-Level Products authorization grid

FREQUENTLY ASKED QUESTIONS

Does Aetna require prior authorization for J0222?

Aetna lists J0222 on Participating provider precertification list for Aetna for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Ambetter require prior authorization for J0222?

Ambetter lists J0222 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does AmeriHealth Caritas require prior authorization for J0222?

AmeriHealth Caritas lists J0222 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for J0222?

Anthem BCBS lists J0222 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Arizona Complete Health require prior authorization for J0222?

Arizona Complete Health lists J0222 on Arizona Complete Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect HCPCS J0222?

There are 8 tracked policy changes affecting HCPCS J0222, including updates from Florida Blue, Arkansas Blue Cross Blue Shield, Independence Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J0222?

Payers that have issued tracked updates for HCPCS J0222 include: Florida Blue, Arkansas Blue Cross Blue Shield, Independence Blue Cross, Mississippi Medicaid (DOM), Aetna, Premera Blue Cross.

How do I get notified when HCPCS J0222 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J0222. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for HCPCS J0222?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for J0222

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for J0222 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Site of Care Guidelines Expansion: Select Oncology and Non-Oncology Provider-Administered Medications

New Drug Waste Reduction Guideline

Policy Criteria Change

MA08.100e, patisiran (Onpattro®) and vutrisiran (Amvuttra®)

08.01.50e, Patisiran (Onpattro®) and vutrisiran (Amvuttra®)

Physician Administered Drugs: Prior Authorization Requirements

Transthyretin-Mediated (ATTR) Amyloidosis (CPB 0939, reviewed 2026-08-10)

Medical Policy and Coding Updates - October 2019

Prior authorization required

Prior authorization required

Prior authorization required

Does Aetna require prior authorization for J0222?

Does Ambetter require prior authorization for J0222?

Does AmeriHealth Caritas require prior authorization for J0222?

Does Anthem BCBS require prior authorization for J0222?

Does Arizona Complete Health require prior authorization for J0222?

What insurance policy changes affect HCPCS J0222?

Which payers have updated policy for HCPCS J0222?

How do I get notified when HCPCS J0222 policy changes?

Why do payers change policies for HCPCS J0222?