`J0256` Alpha 1 proteinase inhibitor

Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10 mg

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 1600 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 1600 units per day (clinical), rationale: Clinical: Data
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J0256

Medicare Part B drug payment limit (ASP, October 2026)

J0256 payment limit: $5.077 per 10 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J0256 (CMS ASP NDC-HCPCS crosswalk, October 2026)

00944-2814-01 Aralast NP, Takeda Pharmaceuticals America, Inc.: 0.1 billing units per package (1 KIT in 1 CARTON * 25 mL in 1 VIAL, GLASS * 25 mL in 1 VIAL)
00944-2815-01 Aralast NP, Takeda Pharmaceuticals America, Inc.: 0.1 billing units per package (1 KIT in 1 CARTON * 50 mL in 1 VIAL * 50 mL in 1 VIAL, GLASS)
13533-0705-01 Prolastin-C, Grifols USA, LLC: 0.1 billing units per package (1 VIAL in 1 CARTON / 20 mL in 1 VIAL)
00053-7201-02 Zemaira, CSL Behring L.L.C.: 0.1 billing units per package (1 KIT in 1 CARTON * 20 mL in 1 VIAL, SINGLE-DOSE * 20 mL in 1 VIAL, SINGLE-DOSE)
00053-7202-02 Zemaira, CSL Behring L.L.C.: 0.1 billing units per package (1 KIT in 1 CARTON * 76 mL in 1 VIAL, SINGLE-USE * 76 mL in 1 VIAL, SINGLE-USE)
00053-7203-02 Zemaira, CSL Behring L.L.C.: 0.1 billing units per package (1 KIT in 1 CARTON * 95 mL in 1 VIAL, SINGLE-USE * 95 mL in 1 VIAL, SINGLE-USE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J0256

152 of 152 payer prior-auth lists that name J0256 require prior authorization or set conditions: Aetna, Arkansas Blue Cross and Blue Shield, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Arkansas Blue Cross and Blue Shield	Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime)	AR	prior auth required		Sep 1, 2023	Medical Benefit Pharmacy Prior Approval List
Arkansas Blue Cross and Blue Shield	Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime)	AR	prior auth required		Sep 1, 2023	Medical Benefit Pharmacy Prior Approval List
Arkansas Blue Cross and Blue Shield	Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime)	AR	prior auth required		Sep 1, 2023	Medical Benefit Pharmacy Prior Approval List
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	site of care: site-of-service review	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	site of care: site-of-service review	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required	site of care: site-of-service review	Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Teamsters group (TYW)	AZ	prior auth required		Sep 1, 2026	Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026)
Aetna	Medicare Advantage	All	prior auth required		Aug 25, 2026	Aetna Medicare Part B drug list (partbname.xml)
Aetna	Commercial	All	prior auth required	site of care: drug and site of care	Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required	Step therapy applies	Aug 25, 2026	Aetna Medicare Part B drug list (partbname.xml)
Cigna	ACA/IFP	All	prior auth required		Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required		Oct 1, 2006	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required		Oct 1, 2006	Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required		Jan 1, 2026	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required	eviCore-managed	Jan 1, 2025	Procedure Code List, Effective 1/1/2025
HealthSpring	Medicare Advantage	All	prior auth required		Jan 1, 2025	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required	NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi
Humana	Humana D-SNP (FL)	FL	prior auth required	Step therapy; NDC required	Jul 1, 2026	H1036-280 Humana Fully Integrated Florida prior authorization and notification list
Humana	Humana D-SNP (FL)	FL	prior auth required	Step therapy; NDC required	Jul 1, 2026	H1036-280 Humana Fully Integrated Florida prior authorization and notification list
Humana	Humana D-SNP (FL)	FL	prior auth required	NDC required	Jul 1, 2026	H1036-280 Humana Fully Integrated Florida prior authorization and notification list
Humana	Humana D-SNP (IL)	IL	prior auth required	NDC required	Jan 1, 2027	Humana Dual Fully Integrated Illinois prior authorization and notification list
Humana	Humana D-SNP (IL)	IL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana Dual Fully Integrated Illinois prior authorization and notification list
Humana	Humana D-SNP (IL)	IL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana Dual Fully Integrated Illinois prior authorization and notification list
Humana	Humana D-SNP (IN)	IN	prior auth required	NDC required	Jan 1, 2027	Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
Humana	Humana D-SNP (IN)	IN	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
Humana	Humana D-SNP (IN)	IN	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
Humana	Humana D-SNP (MI)	MI	prior auth required	Step therapy; NDC required	Oct 14, 2026	Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
Humana	Humana D-SNP (MI)	MI	prior auth required	Step therapy; NDC required	Oct 14, 2026	Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
Humana	Humana D-SNP (MI)	MI	prior auth required	NDC required	Oct 14, 2026	Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
Humana	Humana D-SNP (SC)	SC	prior auth required	NDC required	Jul 1, 2026	Humana Dual Integrated South Carolina prior authorization and notification list
Humana	Humana D-SNP (SC)	SC	prior auth required	Step therapy; NDC required	Jul 1, 2026	Humana Dual Integrated South Carolina prior authorization and notification list
Humana	Humana D-SNP (SC)	SC	prior auth required	Step therapy; NDC required	Jul 1, 2026	Humana Dual Integrated South Carolina prior authorization and notification list
Humana	Humana D-SNP (VA)	VA	prior auth required	Step therapy; NDC required	Jul 1, 2026	Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
Humana	Humana D-SNP (VA)	VA	prior auth required	NDC required	Jul 1, 2026	Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
Humana	Humana D-SNP (VA)	VA	prior auth required	Step therapy; NDC required	Jul 1, 2026	Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
Humana	Humana Healthy Horizons	FL	prior auth required	NDC required	Jan 1, 2027	Humana Healthy Horizons in Florida Prior Authorization and Notification List
Humana	Humana Healthy Horizons	FL	prior auth required	NDC required	Jan 1, 2027	Humana Healthy Horizons in Florida Prior Authorization and Notification List
Humana	Humana Healthy Horizons	FL	prior auth required	NDC required	Jan 1, 2027	Humana Healthy Horizons in Florida Prior Authorization and Notification List
Humana	Humana Healthy Horizons	KY	prior auth required	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	KY	prior auth required	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	KY	prior auth required	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	LA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
Humana	Humana Healthy Horizons	LA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
Humana	Humana Healthy Horizons	LA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OH	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OH	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OH	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OK	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OK	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OK	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	SC	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Humana	Humana MA and D-SNP	All	prior auth required	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
Humana	Humana MA and D-SNP	All	prior auth required	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
Humana	Humana MA and D-SNP	All	prior auth required	NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
Molina Complete Care (Virginia)	Medicare-only PA matrix for D-SNP	VA	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of Arizona	Medicare-only PA matrix for D-SNP	AZ	prior auth required		Jan 1, 2022	Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of California	Medicare Advantage	CA	prior auth required		Jul 1, 2021	Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of Florida	Medicare Advantage	FL	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of Idaho	Medicare Advantage	ID	prior auth required		Apr 1, 2021	Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Exchange	MI	prior auth required		Jul 1, 2021	Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicare Advantage	NM	prior auth required		Jan 1, 2021	Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required	Molina follows New Mexico Senate Bill 39 and waives PA where applicable	Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01

Payer coverage policies that name J0256

J0256 appears in 18 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, BlueCross BlueShield of South Carolina, Centene, Cigna, Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Alpha1-Proteinase Inhibitors (0145)	covered if criteria are met	Mar 24, 2026	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range J0120-J0270)	Mar 5, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Alpha1 Proteinase Inhibitors (S.5.01.528)	listed, no stance		payer document
Blue Cross & Blue Shield of Mississippi	Alpha1 Proteinase Inhibitors (L.5.01.528)	listed, no stance		payer document
Blue Cross Blue Shield of Massachusetts	Med UM Policy (033)	covered if criteria are met		payer document
BlueCross BlueShield of South Carolina	Alpha-1 Proteinase Inhibitors (CAM 941)	listed, no stance	Nov 1, 2025	payer document
Centene	Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, (CP.PHAR.94)	covered if criteria are met	Feb 1, 2026	payer document
Cigna	Alpha1-Proteinase Inhibitor Products	covered if criteria are met	Jun 1, 2026	payer document
Premera Blue Cross	(effective November 6, 2026) Site of Service: Drugs and Biologic Agents	listed, no stance	Jul 14, 2026	payer document
Premera Blue Cross	Alpha1-Proteinase Inhibitors (5.01.624)	listed, no stance	May 25, 2026	payer document
Premera Blue Cross	Site of Service: Drugs and Biologic Agents	listed, no stance	Jul 14, 2026	payer document
UnitedHealthcare	Alpha1-Proteinase Inhibitors (2025D0067J)	listed, no stance	Nov 1, 2025	payer document
UnitedHealthcare	Alpha1-Proteinase Inhibitors (CS2026D0067P)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Alpha1-Proteinase Inhibitors (for Indiana Only) (CSIND0067.06)	listed, no stance	Nov 1, 2025	payer document
UnitedHealthcare	Provider Administered Drugs – Site of Care (CS2026D0121P)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Provider Administered Drugs – Site of Care (2026D0121W)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Provider Administered Drugs – Site of Care (for Ohio Only) (CSOH2026D0121.I)	listed, no stance	Aug 1, 2026	payer document
Wellmark Blue Cross Blue Shield	Alpha1-Proteinase Inhibitors (05.02.39)	listed, no stance	Apr 1, 2026	payer document

Recent prior-auth changes

Oct 14, 2026: PA removed, Humana
Jan 1, 2026: conditions changed, Blue Cross and Blue Shield of Illinois
Nov 1, 2025: conditions changed, Blue Cross and Blue Shield of Illinois

Medicaid fee-for-service

Prior authorization required or conditional in VA, VT.

AZ: $5.10 (asc), effective Oct 1, 2026
FL: $1600.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $8225.60 (practitioner), effective Apr 1, 2026
IN: $5.53 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2026
KY: $5.37 (asc), effective Jan 1, 2026
MS: $4.15 (comprehensive, facility), effective Oct 1, 2025
NE: $5.13 (injectables), effective Jul 1, 2026
OH: $5.13 (provider_administered_drugs), effective Jul 1, 2026
OK: $5.13 (physician, non-facility), effective Jul 1, 2026
TX: $5.37 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $5.13 (medical), effective Jul 1, 2026
VT: $4.15 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $5.13 (professional_administered_drugs), effective Jul 1, 2026
WY: $2.22 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

J0256 Alpha 1 proteinase inhibitor