J0644 Inj, leucovorin cal (avyxa)Injection, leucovorin calcium (avyxa), 1 mg
J0644 payment limit: $2.625 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
83831-0147-05 Vykoura, Avyxa Pharma, LLC: 50 billing units per package (1 VIAL, SINGLE-USE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-USE)83831-0148-35 Vykoura, Avyxa Pharma, LLC: 350 billing units per package (1 VIAL, SINGLE-USE in 1 CARTON / 35 mL in 1 VIAL, SINGLE-USE)83831-0149-50 Vykoura, Avyxa Pharma, LLC: 500 billing units per package (1 VIAL, SINGLE-USE in 1 CARTON / 50 mL in 1 VIAL, SINGLE-USE)Status E: excluded from the PFS by regulation.
1 of 1 payer prior-auth lists that name J0644 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 |
J0644 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.