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J1305

PAYER POLICY CHANGES

J1305 Insurance Policy Changes

HCPCS J1305 is officially defined as "Injection, evinacumab-dgnb, 5mg." HCPCS J1305 is referenced in 11 tracked payer policy changes from Florida Blue, Colorado Medicaid, and 3 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J1305 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.
Colorado Medicaid · Effective Oct 1, 2025High impact
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500530 - 10/2025)
Professional claims (CMS 1500) are reduced by the 1.6% increase previously applied to fee-for-service rates for dates of service on or after October 1, 2025, with targeted rate reductions for dental codes and Pediatric Behavioral Therapy codes effective October 1, 2025. Manually priced DMEPOS and prosthetics claims that follow the MSRP less or invoice acquisition plus methods are reduced to MSRP less 13.78% or invoice acquisition cost plus 24.06%, effective October 1, 2025. Continuous glucose monitor products and supplies must carry the NDC, the HCPCS code and the modifier combination on claims beginning November 1, 2025, and CGMs for members enrolled in physical health managed care plans must be billed as fee-for-service claims.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
MA08.133e, Evinacumab-dgnb (Evkeeza®)
Independence Blue Cross updated its Medicare Advantage coverage policy for evinacumab-dgnb (Evkeeza) effective 11/02/2026. The policy expands eligibility by lowering the minimum age from 12 years to 1 year, reducing the untreated LDL-C threshold from 500 mg/dL to 400 mg/dL, and removing requirements for treated LDL-C levels and parental cholesterol documentation. For children ages 1–10, the treatment goal LDL-C is now 130 mg/dL (or 100 mg/dL with additional risk factors), with no prior therapies required.
Independence Blue Cross · Effective Nov 2, 2026Medium impact
08.01.76e, Evinacumab-dgnb (Evkeeza®)
Independence Blue Cross expanded Evkeeza (evinacumab-dgnb) coverage for homozygous familial hypercholesterolemia to include children aged 1 year or older (previously 5 years), lowered the untreated LDL-C threshold from 500 mg/dL to 400 mg/dL, and removed prior requirements for treated LDL-C levels and parental cholesterol documentation. These changes are effective 11/02/2026.
Independence Blue Cross · Effective Oct 1, 2025Medium impact
MA08.133d, Evinacumab-dgnb (Evkeeza®)
Independence Blue Cross updated Medicare Advantage policy MA08.133d on October 1, 2025, replacing the ICD-10 diagnosis code E78.01 (Familial hypercholesterolemia) with E78.010 (Homozygous familial hypercholesterolemia [HoFH]) for Evinacumab-dgnb (Evkeeza) coverage. This diagnostic code change requires billing teams to use the more specific HoFH code for all new and existing claims to ensure proper reimbursement under the medical benefit (Part B).
Independence Blue Cross · Effective Oct 1, 2025Medium impact
MA08.133d, Evinacumab-dgnb (Evkeeza®)
Independence Blue Cross updated policy MA08.133d for Evinacumab-dgnb (Evkeeza) effective 10/01/2025, replacing the ICD-10 diagnosis code E78.01 (Familial hypercholesterolemia) with E78.010 (Homozygous familial hypercholesterolemia [HoFH]). This diagnostic code change requires billing teams to use the more specific HoFH code for all claims going forward. The policy itself was reissued 12/10/2025 with no substantive coverage criteria changes.
Independence Blue Cross · Effective Oct 1, 2025Medium impact
08.01.76d, Evinacumab-dgnb (Evkeeza®)
Independence Blue Cross reissued policy 08.01.76d for Evinacumab-dgnb (Evkeeza) with a diagnostic code change: the non-specific code E78.01 (Familial hypercholesterolemia) has been replaced with the more specific code E78.010 (Homozygous familial hypercholesterolemia [HoFH]). No clinical coverage criteria changed. Billing teams must update claim submission to use the new ICD-10 code effective October 1, 2025.
Independence Blue Cross · Effective Oct 1, 2025Medium impact
08.01.76d, Evinacumab-dgnb (Evkeeza®)
Independence Blue Cross reissued policy 08.01.76d with a diagnostic code refinement: the broad code E78.01 (Familial hypercholesterolemia) has been replaced with the more specific code E78.010 (Homozygous familial hypercholesterolemia [HoFH]) effective 10/01/2025. Coverage criteria, dosing, and clinical requirements for Evkeeza (evinacumab-dgnb) remain unchanged. Billing teams must update claim submission and prior authorization systems to use the new ICD-10 code.
Aetna · Identified Aug 13, 2026Medium impact
Evinacumab-dgnb (Evkeeza) (CPB 0989, reviewed 2026-04-10)
Aetna's Clinical Policy Bulletin 0989 covers Evkeeza (evinacumab-dgnb) for homozygous familial hypercholesterolemia (HoFH) in members 1 year of age or older when the listed criteria are met, and precertification is required for all Aetna participating providers and members in applicable plan designs. For commercial plans, the Site of Care Utilization Management Policy for Specialty Drug Infusions also applies. The recommended dose is 15 mg/kg by intravenous infusion over 60 minutes once every 4 weeks, and the policy considers evinacumab experimental, investigational, or unproven for chylomicronemia, hypertriglyceridemia, and lipodystrophies.
Premera Blue Cross · Identified Jun 18, 2026Medium impact
Medical Policy and Coding Updates - October 2021
This Premera medical policy and coding update lists changes from October 2021. Effective October 1, 2021, the Diagnosis and Treatment of Sacroiliac Joint Pain policy 6.01.527 replaced policy 6.01.23, and injection of an anesthetic to diagnose sacroiliac joint pain was removed. Site of service review was added for medical necessity on single-level cervical decompression and fusion and single-level lumbar fusion, effective January 7, 2022, and coding changes effective October 1, 2021 added review for investigative care, medical necessity or prior authorization to several codes, including 27280, C9084, Q2054, J9318, J9319 and J1426.

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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 J1305?

Aetna lists J1305 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 J1305?

Ambetter lists J1305 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 J1305?

AmeriHealth Caritas lists J1305 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 J1305?

Anthem BCBS lists J1305 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 J1305?

Arizona Complete Health lists J1305 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 J1305?

There are 11 tracked policy changes affecting HCPCS J1305, including updates from Florida Blue, Colorado Medicaid, Independence Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J1305?

Payers that have issued tracked updates for HCPCS J1305 include: Florida Blue, Colorado Medicaid, Independence Blue Cross, Aetna, Premera Blue Cross.

How do I get notified when HCPCS J1305 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J1305. 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 J1305?

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 J1305

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for J1305 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

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500530 - 10/2025)

MA08.133e, Evinacumab-dgnb (Evkeeza®)

08.01.76e, Evinacumab-dgnb (Evkeeza®)

MA08.133d, Evinacumab-dgnb (Evkeeza®)

MA08.133d, Evinacumab-dgnb (Evkeeza®)

08.01.76d, Evinacumab-dgnb (Evkeeza®)

08.01.76d, Evinacumab-dgnb (Evkeeza®)

Evinacumab-dgnb (Evkeeza) (CPB 0989, reviewed 2026-04-10)

Medical Policy and Coding Updates - October 2021

Prior authorization required

Prior authorization required

Prior authorization required

Does Aetna require prior authorization for J1305?

Does Ambetter require prior authorization for J1305?

Does AmeriHealth Caritas require prior authorization for J1305?

Does Anthem BCBS require prior authorization for J1305?

Does Arizona Complete Health require prior authorization for J1305?

What insurance policy changes affect HCPCS J1305?

Which payers have updated policy for HCPCS J1305?

How do I get notified when HCPCS J1305 policy changes?

Why do payers change policies for HCPCS J1305?