J1957 Injection levetiracetam 5 mgInjection, levetiracetam, 5 mg
J1957 payment limit: $0.013 per 5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
50474-0002-63 Keppra, UCB, Inc.: 1000 billing units per package (10 VIAL, SINGLE-USE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-USE)72485-0106-10 Levetiracetam, Armas Pharmaceuticals Inc.: 1000 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)72485-0106-25 Levetiracetam, Armas Pharmaceuticals Inc.: 2500 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)72572-0360-25 Levetiracetam, Civica, Inc.: 2500 billing units per package (25 VIAL in 1 CARTON / 5 mL in 1 VIAL)55150-0177-05 Levetiracetam, Eugia US LLC: 1000 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)63323-0400-05 Levetiracetam, FreseniUS Kabi USA, LLC: 1000 billing units per package (10 VIAL, SINGLE-USE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-USE)63323-0400-44 Levetiracetam, FreseniUS Kabi USA, LLC: 1000 billing units per package (10 VIAL, SINGLE-USE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-USE)00143-9574-25 Levetiracetam, Hikma Pharmaceuticals USA Inc.: 2500 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)00143-9673-25 Levetiracetam, Hikma Pharmaceuticals USA Inc.: 2500 billing units per package (25 VIAL, GLASS in 1 CARTON / 5 mL in 1 VIAL, GLASS)67457-0790-05 Levetiracetam, Mylan Institutional LLC: 1000 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)72205-0120-07 Levetiracetam, Novadoz Pharmaceuticals LLC: 1000 billing units per package (10 VIAL in 1 CARTON / 5 mL in 1 VIAL)72205-0120-25 Levetiracetam, Novadoz Pharmaceuticals LLC: 2500 billing units per package (25 VIAL in 1 CARTON / 5 mL in 1 VIAL)00409-1886-02 Levetiracetam, Pfizer Inc: 2500 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)00409-2011-25 Levetiracetam, Pfizer Inc: 2500 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE)25021-0780-05 Levetiracetam, Sagent Pharmaceuticals: 1000 billing units per packageStatus E: excluded from the PFS by regulation.
J1957 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.