J2760 Phentolaine mesylate injInjection, phentolamine mesylate, up to 5 mg
J2760 payment limit: $296.849 per 5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
00143-9564-01 Phentolamine Mesylate, Hikma Pharmaceuticals USA Inc.: 1 billing unit per package (1 VIAL in 1 BOX / 1 mL in 1 VIAL)00143-9564-10 Phentolamine Mesylate, Hikma Pharmaceuticals USA Inc.: 10 billing units per package (10 VIAL in 1 BOX / 1 mL in 1 VIAL)Status E: excluded from the PFS by regulation.
1 of 1 payer prior-auth lists that name J2760 require prior authorization or set conditions: UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
J2760 appears in 4 coverage policies from Aetna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Complex Regional Pain Syndrome (CRPS): Diagnosis (0147) | not covered | Mar 30, 2026 | payer document |
| Aetna | Complex Regional Pain Syndrome (CRPS): Treatments (0447) | listed, no stance | Jul 16, 2026 | payer document |
| Aetna | Erectile Dysfunction and Peyronie's Disease (0007) | covered if criteria are met | Jul 29, 2026 | payer document |
| Aetna | Injectable Medications (0020) | listed, no stance (range J2550-J3520) | Mar 5, 2026 | payer document |
Prior authorization required or conditional in NY.
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.