`J3263` Inj, toripalimab-tpzi, 1 mg

Injection, toripalimab-tpzi, 1 mg

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 480 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 480 units per day (clinical), rationale: CMS Policy
DME supplier: max 480 units per day (clinical), rationale: CMS Policy

Medicare pricing for J3263

Medicare Part B drug payment limit (ASP, October 2026)

J3263 payment limit: $40.658 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J3263 (CMS ASP NDC-HCPCS crosswalk, October 2026)

70114-0340-01 Loqtorzi, Coherus BioSciences, Inc.: 240 billing units per package (1 VIAL, GLASS in 1 CARTON / 6 mL in 1 VIAL, GLASS)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J3263

54 of 54 payer prior-auth lists that name J3263 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans, UnitedHealthcare, and others.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	eviCore-delegated groups	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	Other groups: AZ Blue	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required		Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Teamsters group (TYW)	AZ	prior auth required		Sep 1, 2026	Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026)
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required	site of care: drug and site of care	Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required		Aug 25, 2026	Aetna Medicare Part B drug list (partbname.xml)
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jul 1, 2024	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	May be delegated to eviCore for some clients	Jul 1, 2024	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jul 1, 2024	Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required	Carelon-managed	Aug 1, 2025	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Oct 1, 2024	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpring	Medicare Advantage	All	prior auth required		Jan 1, 2025	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi
Humana	Humana D-SNP (FL)	FL	prior auth required		Jul 1, 2026	H1036-280 Humana Fully Integrated Florida prior authorization and notification list
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois prior authorization and notification list
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
Humana	Humana D-SNP (MI)	MI	prior auth required		Oct 14, 2026	Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
Humana	Humana D-SNP (SC)	SC	prior auth required		Jul 1, 2026	Humana Dual Integrated South Carolina prior authorization and notification list
Humana	Humana D-SNP (VA)	VA	prior auth required		Jul 1, 2026	Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
Humana	Humana Healthy Horizons	FL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Florida Prior Authorization and Notification List
Humana	Humana Healthy Horizons	KY	prior auth required		Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	LA	prior auth required		Oct 14, 2026	Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OH	prior auth required		Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OK	prior auth required		Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	SC	prior auth required		Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required		Oct 14, 2026	Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jul 1, 2024	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required	cancer dx via Evolent	Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Texas	Exchange	TX	prior auth required		Jul 1, 2024	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required	cancer dx via Evolent	Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	site of care: outpatient	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth under conditions	site of care: outpatient	Jan 1, 2026	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	site of care: outpatient	Jan 1, 2026	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth under conditions	site of care: outpatient	Jan 1, 2026	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth under conditions	site of care: outpatient	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth under conditions	site of care: outpatient	Sep 1, 2026	Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community

Payer coverage policies that name J3263

J3263 appears in 15 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Injectable Medications (0020)	listed, no stance (range J2550-J3520)	Mar 5, 2026	payer document
Aetna	Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (0892)	listed, no stance	Jul 16, 2026	payer document
Aetna	Toripalimab-tpzi (Loqtorzi) (1049)	covered if criteria are met	Oct 5, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Injectable Oncology (L.5.01.561)	listed, no stance		payer document
Blue Cross & Blue Shield of Mississippi	Injectable Oncology (S.5.01.561)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Loqtorzi (toripalimab-tpzi) (CAM 935)	listed, no stance	Jul 1, 2026	payer document
Centene	Toripalimab-tpzi (Loqtorzi) (CP.PHAR.668)	covered if criteria are met	Feb 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Oncology and Supportive Care Medications (RX502.061) oysk \| Hycleta™	listed, no stance	Jan 1, 2027	payer document
Premera Blue Cross	Immune Checkpoint Inhibitors (5.01.591)	listed, no stance	Aug 11, 2026	payer document
UnitedHealthcare	Maximum Dosage and Frequency (CS2026D0034AV)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Maximum Dosage and Frequency (2026D0034AU)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Medicare Part B Step Therapy Programs (IAP.001.30) Preferred	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Oncology Medication Clinical Coverage (CS2026D0030AR)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Oncology Medication Clinical Coverage (2026D0030AR)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Oncology Medication Clinical Coverage (for Pennsylvania Only) (CSPA2026D0030II)	listed, no stance	Jul 1, 2026	payer document

Recent prior-auth changes

Oct 14, 2026: PA removed, Humana
Mar 1, 2026: PA added, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, Humana
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA added, Rocky Mountain Health Plans
Jan 1, 2026: PA added, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in VA, VT, WA.

AZ: $38.20 (asc), effective Oct 1, 2026
FL: $540.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $38.91 (practitioner), effective Apr 1, 2026
IN: $36.29 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2026
KS: $40.66 (asc, facility), effective Oct 1, 2026
KY: $40.21 (asc), effective Jan 1, 2026
LA: $40.89 (professional), effective Jul 1, 2026
MA: $33.38 (dme_rates), effective Mar 1, 2026
MS: $39.99 (comprehensive), effective Jul 1, 2026
NE: $40.89 (injectables), effective Jul 1, 2026
OH: $39.99 (provider_administered_drugs), effective Jul 1, 2026
OK: $40.89 (physician, non-facility), effective Jul 1, 2026
TX: $40.21 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $40.89 (medical), effective Jul 1, 2026
VT: $29.95 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $40.89 (professional_administered_drugs), effective Jul 1, 2026
WY: $17.31 (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.

J3263 Inj, toripalimab-tpzi, 1 mg