HCPCS Level II › J codes J2790 Rho d immune globulin injInjection, rho d immune globulin, human, full dose, 300 micrograms (1500 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: Clinical: Data Outpatient hospital: max 3 units per day (clinical), rationale: Clinical: Data DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for J2790 Medicare Part B drug payment limit (ASP, October 2026) J2790 payment limit: $82.081 per 300 MCG (1500 IU), effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
NDCs that bill under J2790 (CMS ASP NDC-HCPCS crosswalk, October 2026) 13533-0631-02 HyperRho S/D, Grifols USA, LLC: 1 billing unit per package (1 SYRINGE in 1 CARTON / 1 mL in 1 SYRINGE)13533-0631-11 HyperRho S/D, Grifols USA, LLC: 10 billing units per package (10 CARTON in 1 CARTON / 1 SYRINGE in 1 CARTON / 1 mL in 1 SYRINGE)00562-7805-01 Rhogam, Kedrion Biopharma Inc: 1 billing unit per package (1 POUCH in 1 CARTON / 1 INJECTION, SOLUTION in 1 POUCH)00562-7805-05 Rhogam, Kedrion Biopharma Inc: 5 billing units per package (5 POUCH in 1 CARTON / 1 INJECTION, SOLUTION in 1 POUCH)00562-7805-25 Rhogam, Kedrion Biopharma Inc: 25 billing units per package (25 POUCH in 1 CARTON / 1 INJECTION, SOLUTION in 1 POUCH)Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for J2790 Payer coverage policies that name J2790 J2790 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: $85.13 (outpatient_hospital), effective Jul 1, 2026 FL: $1.00 (physician_administered_drugs), effective Jan 1, 2026 IL: $76.77 (practitioner), effective Apr 1, 2026 IN: $76.14 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2026 KS: $82.08 (default), effective Oct 1, 2026 KY: $0.00 (asc), effective Jan 1, 2026 LA: $85.13 (professional), effective Jul 1, 2026 MS: $78.90 (comprehensive), effective Jul 1, 2026 NE: $85.12 (injectables), effective Jul 1, 2026 OH: $85.12 (provider_administered_drugs), effective Jul 1, 2026 OK: $85.13 (physician, non-facility), effective Jul 1, 2026 TX: $80.53 (hhsc_family_planning_program, Hhsc Family Planning Program), effective Sep 1, 2026 VA: $85.12 (medical), effective Jul 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $85.13 (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.