HCPCS Level II › J codes J2788 Rho d immune globulin 50 mcgInjection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.)
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: Prescribing Information Outpatient hospital: max 1 units per day (clinical), rationale: Prescribing Information DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for J2788 Medicare Part B drug payment limit (ASP, October 2026) J2788 payment limit: $27.653 per 50 MCG (250 IU), effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
NDCs that bill under J2788 (CMS ASP NDC-HCPCS crosswalk, October 2026) 13533-0661-06 HyperRho S/D, Grifols USA, LLC: 10 billing units per package (10 SYRINGE in 1 CARTON / 1 mL in 1 SYRINGE)Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for J2788 Payer coverage policies that name J2788 J2788 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Immune Globulins for Post-Exposure Prophylaxis (0544) covered if criteria are met Oct 7, 2026 payer document Aetna Injectable Medications (0020) listed, no stance (range J2550-J3520) Mar 5, 2026 payer document
Medicaid fee-for-service AZ: $25.54 (outpatient_hospital), effective Jul 1, 2026 FL: $1.00 (physician_administered_drugs), effective Jan 1, 2026 IL: $27.52 (practitioner), effective Apr 1, 2026 IN: $25.84 (professional, Advanced Practice Nurse (85%), non-facility), effective Jul 1, 2018 KS: $27.65 (default), effective Oct 1, 2026 KY: $0.00 (asc), effective Jan 1, 2026 LA: $25.54 (professional), effective Jul 1, 2026 MS: $27.52 (comprehensive), effective Jul 1, 2026 NE: $25.54 (injectables), effective Jul 1, 2026 OH: $27.52 (provider_administered_drugs), effective Jul 1, 2026 OK: $25.54 (physician, non-facility), effective Jul 1, 2026 TX: $22.93 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026 VA: $25.54 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $25.54 (professional_administered_drugs), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), 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.