J0643 Inj leucovorin calcium 1 mgInjection, leucovorin calcium, not otherwise specified, 1 mg
J0643 payment limit: $0.054 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
68001-0416-36 Leucovorin Calcium, BluePoint Laboratories: 100 billing units per package (1 VIAL in 1 BOX / 10 mL in 1 VIAL)68001-0417-37 Leucovorin Calcium, BluePoint Laboratories: 200 billing units per package (1 VIAL in 1 BOX, UNIT-DOSE / 20 mL in 1 VIAL)68001-0418-38 Leucovorin Calcium, BluePoint Laboratories: 350 billing units per package (1 VIAL in 1 BOX, UNIT-DOSE / 17.5 mL in 1 VIAL)68001-0648-36 Leucovorin Calcium, BluePoint Laboratories: 100 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)68001-0649-37 Leucovorin Calcium, BluePoint Laboratories: 200 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE)68001-0650-38 Leucovorin Calcium, BluePoint Laboratories: 350 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 17.5 mL in 1 VIAL, SINGLE-DOSE)63323-0631-10 Leucovorin Calcium, FreseniUS Kabi USA, LLC: 100 billing units per package (1 VIAL, SINGLE-USE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-USE)63323-0631-50 Leucovorin Calcium, FreseniUS Kabi USA, LLC: 500 billing units per package (1 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE)63323-0710-50 Leucovorin Calcium, FreseniUS Kabi USA, LLC: 200 billing units per package (1 VIAL in 1 BOX / 20 mL in 1 VIAL)63323-0711-00 Leucovorin Calcium, FreseniUS Kabi USA, LLC: 500 billing units per package (1 VIAL in 1 BOX / 50 mL in 1 VIAL)68462-0767-35 Leucovorin Calcium, Glenmark Pharmaceuticals Inc., Usa: 350 billing units per package (1 VIAL in 1 CARTON / 17.5 mL in 1 VIAL)00143-9368-01 Leucovorin Calcium, Hikma Pharmaceuticals USA Inc.: 200 billing units per package (1 VIAL in 1 BOX, UNIT-DOSE / 20 mL in 1 VIAL)00143-9552-01 Leucovorin Calcium, Hikma Pharmaceuticals USA Inc.: 350 billing units per package (1 VIAL in 1 BOX, UNIT-DOSE / 17.5 mL in 1 VIAL)00143-9553-01 Leucovorin Calcium, Hikma Pharmaceuticals USA Inc.: 200 billing units per package (1 VIAL in 1 BOX, UNIT-DOSE / 20 mL in 1 VIAL)00143-9554-01 Leucovorin Calcium, Hikma Pharmaceuticals USA Inc.: 100 billing units per package (1 VIAL in 1 BOX / 10 mL in 1 VIAL)00143-9555-01 Leucovorin Calcium, Hikma Pharmaceuticals USA Inc.: 50 billing units per package (1 VIAL in 1 BOX / 5 mL in 1 VIAL)71288-0160-10 Leucovorin Calcium, Meitheal Pharmaceuticals Inc.: 50 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)71288-0161-20 Leucovorin Calcium, Meitheal Pharmaceuticals Inc.: 100 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)71288-0162-30 Leucovorin Calcium, Meitheal Pharmaceuticals Inc.: 200 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE)71288-0163-30 Leucovorin Calcium, Meitheal Pharmaceuticals Inc.: 350 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 17.5 mL in 1 VIAL, SINGLE-DOSE)71288-0164-50 Leucovorin Calcium, Meitheal Pharmaceuticals Inc.: 500 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-DOSE)67457-0528-10 Leucovorin Calcium, Mylan Institutional LLC: 100 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)67457-0529-20 Leucovorin Calcium, Mylan Institutional LLC: 200 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 20 mL in 1 VIAL, SINGLE-DOSE)67457-0530-35 Leucovorin Calcium, Mylan Institutional LLC: 350 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 17.5 mL in 1 VIAL, SINGLE-DOSE)25021-0813-10 Leucovorin Calcium, Sagent Pharmaceuticals: 500 billing units per package (10 VIAL in 1 CARTON / 5 mL in 1 VIAL)25021-0814-30 Leucovorin Calcium, Sagent Pharmaceuticals: 100 billing units per package (1 VIAL in 1 CARTON / 10 mL in 1 VIAL)25021-0815-30 Leucovorin Calcium, Sagent Pharmaceuticals: 200 billing units per package (1 VIAL in 1 CARTON / 20 mL in 1 VIAL)25021-0816-30 Leucovorin Calcium, Sagent Pharmaceuticals: 350 billing units per package (1 VIAL in 1 CARTON / 17.5 mL in 1 VIAL)25021-0816-67 Leucovorin Calcium, Sagent Pharmaceuticals: 350 billing units per package25021-0828-50 Leucovorin Calcium, Sagent Pharmaceuticals: 500 billing units per package (1 VIAL in 1 CARTON / 50 mL in 1 VIAL)70436-0116-82 Leucovorin Calcium, Slate Run Pharmaceuticals: 500 billing units per package (10 VIAL in 1 BOX / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)70436-0117-80 Leucovorin Calcium, Slate Run Pharmaceuticals: 100 billing units per package (1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)70436-0118-80 Leucovorin Calcium, Slate Run Pharmaceuticals: 200 billing units per package (1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)70436-0119-80 Leucovorin Calcium, Slate Run Pharmaceuticals: 350 billing units per package (1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)70436-0120-80 Leucovorin Calcium, Slate Run Pharmaceuticals: 500 billing units per package (500 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)Status E: excluded from the PFS by regulation.
1 of 1 payer prior-auth lists that name J0643 require prior authorization or set conditions: HealthSpring.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| HealthSpring | Medicare Advantage | All | prior auth required | Oct 1, 2026 | 2026 Q4 Prior Authorization List |
J0643 appears in 1 coverage policy from Aetna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Injectable Medications (0020) | listed, no stance (range J0278-J2543) | Mar 5, 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.