J0640 Leucovorin calcium injectionInjection, leucovorin calcium, per 50 mg
Status I: not valid for Medicare (Medicare uses another code).
15 of 15 payer prior-auth lists that name J0640 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Rocky Mountain Health Plans, UnitedHealthcare, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Oncology dx: eviCore | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Non-oncology dx: AZ Blue | 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 | Other groups: AZ Blue | 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 | eviCore-delegated groups | 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 | 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) | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth under conditions | site of care: outpatient | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth under conditions | site of care: outpatient | Jan 1, 2017 | Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care |
| UnitedHealthcare Community Plan | Texas STAR | TX | prior auth under conditions | site of care: outpatient | Jan 1, 2017 | Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h |
| UnitedHealthcare Community Plan | Texas STAR Kids | TX | prior auth under conditions | site of care: outpatient | Jan 1, 2017 | Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth under conditions | site of care: outpatient | Jan 1, 2017 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth under conditions | site of care: outpatient | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
J0640 appears in 16 coverage policies from Aetna, Centene, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Atezolizumab (Tecentriq) and Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza) (0909) | listed, no stance | Sep 28, 2026 | payer document |
| Aetna | Cetuximab (Erbitux) (0684) Afitinib | listed, no stance | Dec 3, 2025 | payer document |
| Aetna | Durvalumab (Imfinzi) (0917) | listed, no stance | Sep 25, 2026 | payer document |
| Aetna | Hematopoietic Colony-Stimulating Factors (CSFs) (0055) | listed, no stance | Jul 16, 2026 | payer document |
| Aetna | Injectable Medications (0020) | listed, no stance (range J0278-J2543) | Mar 5, 2026 | payer document |
| Aetna | Irinotecan Liposome Injection (Onivyde) (0902) | listed, no stance | Feb 24, 2026 | payer document |
| Aetna | Levoleucovorin (Khapzory) (0889) | listed, no stance | Dec 4, 2025 | payer document |
| Aetna | Pharmacogenetic and Pharmacodynamic Testing (0715) | listed, no stance | Oct 8, 2026 | payer document |
| Aetna | Ramucirumab (Cyramza) (0883) | listed, no stance | Jun 3, 2026 | payer document |
| Aetna | Ziv-Aflibercept (Zaltrap) (0842) | listed, no stance | Dec 9, 2025 | payer document |
| Centene | Leucovorin Injection (CP.PHAR.393) | covered if criteria are met | Nov 1, 2025 | payer document |
| UnitedHealthcare | Medicare Part B Step Therapy Programs (IAP.001.30) Preferred | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (CS2026D0030AR) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (2026D0030AR) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (for Ohio Only) (CSOH2026D0030.F) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (for Pennsylvania Only) (CSPA2026D0030II) | listed, no stance | Jul 1, 2026 | payer document |
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.