J1105 Dexmedetomidine film, 1 mcgDexmedetomidine, oral, 1 mcg
Status N: non-covered service.
11 of 11 payer prior-auth lists that name J1105 require prior authorization or set conditions: Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of New Mexico, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky).
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2024 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicaid | 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 New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | Jan 1, 2024 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | State exception | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
J1105 appears in 3 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Injectable Medications (0020) | listed, no stance (range J0278-J2543) | Mar 5, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Igalmi Dexmedetomidine (S.5.01.592) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Igalmi Dexmedetomidine (L.5.01.592) | not covered | payer document |
Prior authorization required or conditional in WA.
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.