`J9017` Arsenic trioxide injection

Injection, arsenic trioxide, 1 mg

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

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 30 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 30 units per day (clinical), rationale: Clinical: Data
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J9017

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

J9017 payment limit: $3.837 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J9017 (CMS ASP NDC-HCPCS crosswalk, October 2026)

70121-1483-07 Arsenic Trioxide, Amneal Pharmaceuticals, LLC: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)
70121-1658-01 Arsenic Trioxide, Amneal Pharmaceuticals, LLC: 120 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 6 mL in 1 VIAL, SINGLE-DOSE)
70860-0217-10 Arsenic Trioxide, Athenex Pharmaceutical Division, LLC: 10 billing units per package
63323-0637-10 Arsenic Trioxide, FreseniUS Kabi USA, LLC: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)
23155-0869-41 Arsenic Trioxide, Heritage Pharmaceuticals Inc.: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)
23155-0870-41 Arsenic Trioxide, Heritage Pharmaceuticals Inc.: 120 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 6 mL in 1 VIAL, SINGLE-DOSE)
50742-0438-10 Arsenic Trioxide, Ingenus Pharmaceuticals LLC: 10 billing units per package (1 VIAL, GLASS in 1 CARTON / 10 mL in 1 VIAL, GLASS)
14789-0600-10 Arsenic Trioxide, Nexus Pharmaceuticals, LLC: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)
69918-0720-02 Arsenic Trioxide, Nordic Pharma, Inc: 20 billing units per package
69918-0720-10 Arsenic Trioxide, Nordic Pharma, Inc: 100 billing units per package (10 VIAL, GLASS in 1 CARTON / 10 mL in 1 VIAL, GLASS)
72603-0339-10 Arsenic Trioxide, Northstar RxLLC: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)
72205-0171-07 Arsenic Trioxide, Novadoz Pharmaceuticals LLC: 100 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-DOSE)
72205-0172-07 Arsenic Trioxide, Novadoz Pharmaceuticals LLC: 120 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 6 mL in 1 VIAL, SINGLE-DOSE)
25021-0226-10 Arsenic Trioxide, Sagent Pharmaceuticals: 100 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
25021-0227-06 Arsenic Trioxide, Sagent Pharmaceuticals: 120 billing units per package (10 VIAL in 1 CARTON / 6 mL in 1 VIAL)
00781-3498-94 Arsenic Trioxide, Sandoz Inc.: 12 billing units per package (1 VIAL in 1 CARTON / 6 mL in 1 VIAL)
00781-3498-95 Arsenic Trioxide, Sandoz Inc.: 120 billing units per package (10 VIAL in 1 CARTON / 6 mL in 1 VIAL)
68382-0997-10 Arsenic Trioxide, Zydus Pharmaceuticals (USA) Inc.: 100 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
70710-1610-06 Arsenic Trioxide, Zydus Pharmaceuticals (USA) Inc.: 120 billing units per package (10 VIAL in 1 CARTON / 6 mL in 1 VIAL)
70710-1895-06 Arsenic Trioxide, Zydus Pharmaceuticals (USA) Inc.: 100 billing units per package (10 VIAL in 1 CARTON / 10 mL in 1 VIAL)
70710-1896-06 Arsenic Trioxide, Zydus Pharmaceuticals (USA) Inc.: 120 billing units per package (10 VIAL in 1 CARTON / 6 mL in 1 VIAL)
63459-0601-06 Trisenox, Cephalon, LLC: 120 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 6 mL in 1 VIAL, SINGLE-DOSE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J9017

29 of 35 payer prior-auth lists that name J9017 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, 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		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 under conditions	eviCore-delegated groups only	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)
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2018	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2018	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2018	Master Precertification List (For Health Care Providers)
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	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 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		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 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	Texas CHIP	TX	prior auth under conditions	site of care: outpatient	Jan 1, 2017	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 under conditions	site of care: outpatient	Jan 1, 2017	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 under conditions	site of care: outpatient	Jan 1, 2017	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, 2017	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 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

Payer coverage policies that name J9017

J9017 appears in 18 coverage policies from Aetna, BlueCross BlueShield of South Carolina, Premera Blue Cross.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Antiemetic Therapy (0724)	listed, no stance	Jul 17, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Hodgkin's Disease (0495)	listed, no stance (range J9000-J9999)	Jul 2, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Multiple Myeloma (0497)	listed, no stance (range J9000-J9999)	Aug 5, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496)	listed, no stance (range J9000-J9999)	Aug 6, 2026	payer document
Aetna	Hematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia (0626)	listed, no stance (range J9000-J9999)	Sep 18, 2026	payer document
Aetna	Infusion Pumps (0161)	covered if criteria are met (range J9000-J9999)	Mar 31, 2026	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range J9000-J9999)	Mar 5, 2026	payer document
Aetna	Margetuximab-cmkb (Margenza) (0985)	listed, no stance (range J9000-J9999)	May 27, 2026	payer document
Aetna	Negative Pressure Wound Therapy (0334)	listed, no stance (range J9000-J9999)	Jun 8, 2026	payer document
Aetna	Pertuzumab Products (0973)	listed, no stance (range J9000-J9999)	Apr 27, 2026	payer document
Aetna	Phototherapy and Photochemotherapy (PUVA) for Skin Conditions (0205)	listed, no stance (range J9000-J9999)	May 18, 2026	payer document
Aetna	Revakinagene Taroretcel-lwey (Encelto) (1079)	listed, no stance (range J8501-J9999)	Oct 5, 2026	payer document
Aetna	Tumor Chemoresistance Assays (0758)	listed, no stance (range J9000-J9999)	Dec 2, 2025	payer document
Aetna	Tumor Chemosensitivity Assays (0245)	listed, no stance (range J9000-J9999)	Apr 13, 2026	payer document
BlueCross BlueShield of South Carolina	Hematopoietic Cell Transplantation for Breast Cancer (CAM 80127)	listed, no stance (range J9000-J9999)	Jul 1, 2026	payer document
BlueCross BlueShield of South Carolina	Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (CAM 80124)	unproven / investigational (range J9000-J9999)	Jul 1, 2026	payer document
BlueCross BlueShield of South Carolina	Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome (CAM 80117)	listed, no stance (range J9000-J9999)	Jan 1, 2026	payer document
Premera Blue Cross	Miscellaneous Oncology Drugs (5.01.540)	listed, no stance	Oct 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2026: PA removed, Humana
Nov 1, 2025: PA removed, Blue Cross and Blue Shield of Illinois
Jul 1, 2024: conditions changed, Molina Healthcare of Illinois

Medicaid fee-for-service

AZ: $6.52 (outpatient_hospital), effective Oct 1, 2025
FL: $30.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $6.27 (practitioner), effective Apr 1, 2026
IN: $4.46 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2024
KS: $2.88 (default, Mid Level Practitioner), effective Oct 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
LA: $5.07 (professional), effective Jul 1, 2026
MS: $4.69 (comprehensive, facility), effective Oct 1, 2025
NE: $5.06 (injectables), effective Jul 1, 2026
OH: $6.45 (provider_administered_drugs), effective Jul 1, 2026
OK: $5.07 (physician, non-facility), effective Jul 1, 2026
TX: $7.39 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $5.06 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $5.07 (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.

J9017 Arsenic trioxide injection