HCPCS J1809 is officially defined as "Injection, fosdenopterin, 0.1 mg." HCPCS J1809 is referenced in 15 tracked payer policy changes from Blue Cross Blue Shield of North Dakota, Anthem BCBS, and 9 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J1809 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Blue Cross Blue Shield of North Dakota's August 2026 pharmacy update covers Medicaid Expansion medical drug prior authorization policies, with new policies and coding changes effective October 1, 2026. The most important billing change is the new HCPCS codes that replace older codes, such as Q5172 for Filkri and J9362 for Yondelis, plus added diagnosis codes for several drugs; the commercial pharmacy policies were reviewed with no changes listed.
Effective August 1, 2026, Anthem Virginia is implementing prior authorization, quantity limits, step therapy, and site of care requirements for 13 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before dispensing and verify medical necessity documentation. Patients currently receiving these medications without prior auth will need authorization for continued coverage.
Effective August 1, 2026, Anthem Georgia is implementing new prior authorization, quantity limit, step therapy, and site of care requirements for 17 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before the effective date, as patients currently receiving these medications without authorization will now require approval for continued use.
Florida Blue is expanding their Physician-Administered Drug Program (PADP) effective March 1, 2026, requiring preservice reviews for 25 specific specialty drug codes before administration. Claims will be denied without prior authorization, and providers cannot bill patients for denied charges.
Blue Cross Blue Shield of Rhode Island updated HCPCS Level II codes and modifiers effective October 1, 2025, affecting coverage and reimbursement rules for various procedures. Multiple codes now have different coverage policies for Professional vs Institutional providers, and some require specific modifiers or medical review.
Independence Blue Cross updated policy 08.00.78av to 08.00.78ay, replacing three self-administered drug/biologic HCPCS codes with specific product-based codes effective 10/01/2025: fosdenopterin (J3590→J1809), concizumab-mtci (J3590→J7173), and fitusiran (J3590→J7174). Billing teams must update systems to use the new specific codes instead of the generic J3590 code to ensure proper claim processing under the pharmacy benefit.
Coverage and billing information for the October 2025 quarterly HCPCS update applies to dates of service on or after Oct. 1, 2025. Many of the new codes are noncovered, while covered codes include skin substitute codes A2036 to A2039 and Q4383 to Q4397 reimbursed at a flat, statewide, per-unit rate, and prosthetic codes L6034 to L6039 that require prior authorization and attachment of MSRP documentation or a cost invoice if no MSRP is available. Covered codes requiring prior authorization include J1370, J3403, L6034 to L6039, Q5156, Q5157 and Q5158, and NDC is required for many of the listed drug codes.
With effective dates from March 1, 2026 through June 5, 2026. Deep brain stimulation for treatment-resistant obsessive-compulsive disorder changed from investigational to medically necessary when criteria are met, and carpal tunnel release procedures became subject to site of service ASC review. Radiation therapy codes, including 70472, moved to Carelon review for medical necessity and prior authorization effective June 5, 2026, and the electronic brachytherapy policy was deleted. The update also lists codes that became investigational or non-covered, and many drug criteria changes including preferred product, step therapy and quantity limit updates.
Effective August 1, 2026, Anthem Blue Cross specialty pharmacy policies are changing for New York commercial plans. Seven specialty drugs now require prior authorization, quantity limits, step therapy reviews, or site of care determinations. Billing teams must implement these requirements in their systems to avoid claim denials for patients currently receiving these medications without prior auth.
Effective August 1, 2026, Anthem is implementing new prior authorization, quantity limit, step therapy, and site of care requirements for 16 specialty pharmacy medications across multiple clinical criteria documents. Billing teams must update systems to require prior authorization for these drugs and verify step therapy status (non-preferred medications require step therapy) before claims submission. Patients currently receiving these medications without authorization may be affected, requiring proactive outreach.
Kansas Medicaid (KMAP) is adding 30 new HCPCS codes for coverage and discontinuing 7 existing codes effective October 1, 2025. This affects billing for medical devices, injectable drugs, and other supplies covered under Kansas Medicaid programs.
Michigan Medicaid has updated CPT and HCPCS code coverage effective October 1, 2025, adding new covered codes for various provider types and discontinuing several codes as of September 30, 2025. The policy also provides retroactive coverage for some existing codes dating back to June 2025.
Molina Healthcare of New York is implementing new prior authorization requirements for transplant/gene therapy drugs and skin substitutes effective October 1, 2025, while removing prior auth requirements for certain ASC procedures (33904) unless performed out-of-network.
Coverage and billing information applies to dates of service on or after Oct. 1, 2025 for the new codes in the October 2025 quarterly HCPCS update, and procedure code J0570, buprenorphine implant, resumes coverage for the same dates. Many of the new codes are noncovered, while covered codes include skin substitute codes A2036 to A2039 and Q4383 to Q4397, which are allowed for podiatrists (provider specialty 140), and prosthetic codes L6034 to L6039, which require prior authorization. Discontinued codes C9088, C9174, C9175, C9248, J2150 and S0074 list alternate codes J0668, J9011, J0614, J0759, J2151 and J0525, and an alternate code does not indicate IHCP coverage of that code.
Aetna considers fosdenopterin (Nulibry) medically necessary for molybdenum cofactor deficiency (MoCD) Type A when genetic testing confirms a pathogenic variant in the MOCS1 gene, or when a presumed diagnosis is paired with pending genetic test results and matching clinical signs and symptoms. Precertification of fosdenopterin is required of all Aetna participating providers and members in applicable plan designs. Aetna considers all other indications experimental, investigational, or unproven.
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