`J7174` Injection fitusiran 0.04 mg

Injection, fitusiran, 0.04 mg

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

Medicare pricing for J7174

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

J7174 payment limit: $133.477 per 0.04 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Clotting factor.

NDCs that bill under J7174 (CMS ASP NDC-HCPCS crosswalk, October 2026)

58468-0347-01 Qfitlia, Genzyme Corporation: 500 billing units per package (1 VIAL in 1 CARTON / .2 mL in 1 VIAL)
58468-0348-01 Qfitlia, Genzyme Corporation: 1250 billing units per package (1 SYRINGE in 1 CARTON / .5 mL in 1 SYRINGE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J7174

56 of 56 payer prior-auth lists that name J7174 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Cigna, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of New Mexico, Neighborhood Health Partnership, Oxford Health Plans, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

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	Request from member's PBM	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	Request from member's PBM	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	Request from member's PBM	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	Request from member's PBM	Sep 1, 2026	Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026)
Cigna	ACA/IFP	All	prior auth required		Oct 1, 2025	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required		Oct 1, 2025	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required		Oct 1, 2025	Master Precertification List (For Health Care Providers)
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required	Step therapy; NDC 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	Step therapy; NDC required	Jul 1, 2026	H1036-280 Humana Fully Integrated Florida prior authorization and notification list
Humana	Humana D-SNP (IL)	IL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana Dual Fully Integrated Illinois prior authorization and notification list
Humana	Humana D-SNP (IN)	IN	prior auth required	Step therapy; NDC 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	Step therapy; NDC 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	Step therapy; NDC required	Jul 1, 2026	Humana Dual Integrated South Carolina prior authorization and notification list
Humana	Humana D-SNP (VA)	VA	prior auth required	Step therapy; NDC 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	IN	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Indiana prior authorization and notification list for provider-administered medications
Humana	Humana Healthy Horizons	KY	prior auth required	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OH	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OK	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	SC	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required	NDC 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	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
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 Illinois	Medicaid	IL	prior auth required		Oct 1, 2025	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required	Molina follows New Mexico Senate Bill 39 and waives PA where applicable	Oct 1, 2025	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Oct 1, 2025	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth required		Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		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 required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans 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	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth under conditions	If prior authorization requirements for the drug aren’t met, UnitedHealthcare will call the health care professional’s office within 3 days.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	New Mexico Turquoise Care	NM	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community Plan	Ohio Medicaid	OH	prior auth required		Nov 1, 2025	Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth required		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	TennCare	TN	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth required		Oct 1, 2025	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	TX	prior auth required		Oct 1, 2025	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth required		Oct 1, 2025	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 required		Oct 1, 2025	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 required		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 required		Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
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
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth required		Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Wisconsin BadgerCare Plus and Medicaid SSI	WI	prior auth required		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 J7174

J7174 appears in 9 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Cigna, Premera Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Clotting Factors (0131)	listed, no stance	Apr 23, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Hemophilia Therapies (S.5.01.433)	not covered		payer document
Blue Cross & Blue Shield of Mississippi	Hemophilia Therapies (L.5.01.433)	not covered		payer document
Centene	Fitusiran (Qfitlia) (CP.PHAR.706)	covered if criteria are met	Aug 1, 2026	payer document
Cigna	Hemophilia – Non-Factor Routine Prophylaxis Products – Qfitlia (IP0742)	covered if criteria are met	Sep 1, 2026	payer document
Premera Blue Cross	Pharmacologic Treatment of Hemophilia (5.01.581)	listed, no stance	Aug 11, 2026	payer document
UnitedHealthcare	Clotting Factors, Coagulant Blood Products, & Other Hemostatics (2026D0047AM)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Denied Drug Codes – Pharmacy Benefit Drugs (for Arizona Only) (CS2026D0990AB)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Factor Mimetics and Rebalancing Agents for Hemophilia (CS2026D0047F)	listed, no stance	Apr 1, 2026	payer document

Recent prior-auth changes

Oct 14, 2026: PA added, Humana
Jul 1, 2026: PA added, UnitedHealthcare Community Plan
Feb 1, 2026: PA added, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA removed, UnitedHealthcare Community Plan
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA added, UnitedHealthcare Community Plan
Nov 1, 2025: PA added, uhc:pa:summary-of-changes
Nov 1, 2025: PA added, UnitedHealthcare Community Plan
Nov 1, 2025: PA added, uhc:pa:summary-of-changes

Medicaid fee-for-service

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

AZ: $125.99 (asc), effective Oct 1, 2026
IL: $132.63 (practitioner), effective Apr 1, 2026
IN: $116.28 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2026
KS: $133.48 (asc, facility), effective Oct 1, 2026
MS: $133.25 (comprehensive, facility), effective Oct 1, 2025
NE: $131.20 (injectables), effective Jul 1, 2026
OH: $132.63 (provider_administered_drugs), effective Jul 1, 2026
OK: $131.20 (physician, non-facility), effective Jul 1, 2026
TX: $132.62 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $131.20 (medical), effective Jul 1, 2026
VT: $101.27 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $57.41 (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.

J7174 Injection fitusiran 0.04 mg