J9120 Dactinomycin injectionInjection, dactinomycin, 0.5 mg
J9120 payment limit: $320.899 per 0.5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
55150-0431-01 Dactinomycin, Eugia US LLC: 1 billing unit per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)55150-0928-02 Dactinomycin, Eugia US LLC: 1 billing unit per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)42658-0008-01 Dactinomycin, Hisun Pharmaceuticals USA, Inc: 1 billing unit per package (1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL)71288-0129-02 Dactinomycin, Meitheal Pharmaceuticals Inc.: 1 billing unit per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)67457-0513-05 Dactinomycin, Mylan Institutional Inc.: 1 billing unit per package67457-0928-02 Dactinomycin, Mylan Institutional Inc.: 1 billing unit per package39822-2100-02 Dactinomycin, XGen Pharmaceuticals DJB, Inc.: 1 billing unit per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)Status E: excluded from the PFS by regulation.
15 of 22 payer prior-auth lists that name J9120 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Cigna, HealthSpring, Molina Healthcare of California, 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 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 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 |
J9120 appears in 19 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 | Hematopoietic Colony-Stimulating Factors (CSFs) (0055) | listed, no stance | Jul 16, 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) Page | 63 of 125 | ∞ | listed, no stance | Oct 1, 2026 | payer document |
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.