HCPCS Level II › J codes J1451 Fomepizole, 15 mgInjection, fomepizole, 15 mg
Medicare coverage: Special coverage instructions apply Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 1 units per day (clinical), rationale: Clinical: Data Outpatient hospital: max 200 units per day (clinical), rationale: Prescribing Information DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for J1451 Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for J1451 Payer coverage policies that name J1451 J1451 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
Medicaid fee-for-service AZ: $6.11 (asc), effective Oct 1, 2026 IN: $8.79 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2024 KY: $6.43 (asc), effective Jan 1, 2026 MS: $4.82 (comprehensive, facility), effective Oct 1, 2025 NE: $13.28 (injectables), effective Jul 1, 2026 OH: $6.96 (provider_administered_drugs), effective Apr 1, 2014 TX: $10.47 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Nov 1, 2019 VA: $6.46 (medical), effective Jul 1, 2013 VT: $4.77 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $17.32 (professional_administered_drugs), effective Jul 1, 2026 WY: $2.83 (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.