J9155 Degarelix injection

Injection, degarelix, 1 mg

Medically Unlikely Edits (effective October 1, 2026)

Medicare pricing for J9155

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

J9155 payment limit: $4.509 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J9155 (CMS ASP NDC-HCPCS crosswalk, October 2026)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J9155

73 of 74 payer prior-auth lists that name J9155 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, and others.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross Blue Shield of Arizona (AZ Blue)AZ Blue-administered Medicare Advantage (M2K)AZprior auth requiredSep 1, 2026AZ 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)AZprior auth under conditionseviCore-delegated groups onlySep 1, 2026AZ 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)AZprior auth requiredSep 1, 2026State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Blue Shield of California Promise Health PlanPromise Health Plan Medi-CalCAprior auth requiredSep 1, 2026Medi-Cal Prior Authorization List
AetnaCommercialAllprior auth under conditionsProstate cancer onlyOct 1, 2026Participating provider precertification list for Aetna®
CignaACA/IFPAllprior auth requiredMay be delegated to eviCore for some clientsJul 1, 2021Master Precertification List (For Health Care Providers)
CignaBasic StandardAllprior auth requiredMay be delegated to eviCore for some clientsJul 1, 2021Master Precertification List (For Health Care Providers)
CignaComplete/PHS+/PreferredAllprior auth requiredMay be delegated to eviCore for some clientsJul 1, 2021Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of TexasTexas PA exemption (gold card), outpatient, fully insuredTXprior auth requiredGold-card exemption availableJul 1, 2026BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpringMedicare AdvantageAllprior auth requiredJan 1, 20252026 Q4 Prior Authorization List
HumanaHumana Healthy HorizonsVAprior auth requiredOct 14, 2026Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Molina Complete Care (Virginia)Medicare-only PA matrix for D-SNPVAprior auth requiredJan 1, 2022Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022
Molina Complete Care (Virginia)MedicaidVAprior auth requiredApr 1, 2025Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of ArizonaMedicare-only PA matrix for D-SNPAZprior auth requiredJan 1, 2022Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022
Molina Healthcare of CaliforniaMedicare AdvantageCAprior auth requiredJul 1, 2021Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021
Molina Healthcare of CaliforniaMedicaidCAprior auth requiredApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of FloridaMedicare AdvantageFLprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021
Molina Healthcare of IdahoMedicare AdvantageIDprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021
Molina Healthcare of IdahoMedicaidIDprior auth requiredJan 1, 2025Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of IllinoisMedicaidILprior auth requiredApr 1, 2023Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of IowaMedicaidIAprior auth requiredJul 1, 2023IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of MichiganMedicare AdvantageMIprior auth requiredJul 1, 2026Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of MichiganExchangeMIprior auth requiredJul 1, 2021Molina Healthcare of Michigan PA Matrix, effective 7/1/2021
Molina Healthcare of MississippiMedicaidMSprior auth requiredcancer dx via EvolentJan 1, 2025Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of NevadaMedicaidNVprior auth requiredcancer dx via NCHOct 1, 2022Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New MexicoMedicare AdvantageNMprior auth requiredJan 1, 2021Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021
Molina Healthcare of OhioMedicaid and MyCare Ohio (MMP) MedicaidOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioMedicare and MyCare Ohio (MMP) MedicareOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioExchangeOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of South CarolinaMedicare AdvantageSCprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021
Molina Healthcare of TexasExchangeTXprior auth requiredSep 1, 2019Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of UtahMedicare AdvantageUTprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021
Molina Healthcare of UtahMedicaidUTprior auth requiredJan 1, 2025Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of WashingtonMedicare AdvantageWAprior auth requiredApr 1, 2021Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021
Molina Healthcare of WisconsinMedicare AdvantageWIprior auth requiredOct 1, 2021Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021
Molina Healthcare, Inc. (national grid)Molina national (MHI) Medicare gridAllprior auth requiredOct 1, 2021Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021
Passport by Molina Healthcare (Kentucky)MedicaidKYprior auth requiredcancer dx via EvolentJul 1, 2026Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health PlansRocky Mountain Health Plans CHP+COprior auth requiredOct 1, 2026Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
UnitedHealthcareUnitedHealthcare Complete (Individual & Family plans)Allprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcareUnitedHealthcare Individual Exchange plansAllprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare Community PlanAHCCCS Complete Care (ACC)AZprior auth requiredOct 1, 2026Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community PlanALTCS Developmentally DisabledAZprior auth requiredOct 1, 2026Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community PlanIndiana Hoosier Care ConnectINprior auth requiredOct 1, 2026Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026
UnitedHealthcare Community PlanIndiana PathWays for Aging (MLTSS)INprior auth requiredOct 1, 2026Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026
UnitedHealthcare Community PlanLouisiana Medicaid (Healthy Louisiana)LAprior auth requiredJan 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community PlanMaryland HealthChoiceMDprior auth requiredSep 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community PlanMichigan Medicaid, Healthy Michigan Plan, CSHCSMIprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community PlanMinnesota Metro MedicaidMNprior auth requiredOct 1, 2024Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community PlanMississippi CHIPMSprior auth requiredApr 1, 2025Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community PlanMississippiCANMSprior auth requiredApr 1, 2025Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community PlanNebraska Heritage HealthNEprior auth requiredJul 1, 2026Prior 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 PlanNew Jersey FamilyCareNJprior auth requiredOct 1, 2026Prior 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 PlanNew Mexico Turquoise CareNMprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026
UnitedHealthcare Community PlanOhio MedicaidOHprior auth requiredNov 1, 2025Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan
UnitedHealthcare Community PlanPennsylvania CHIPPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community PlanPennsylvania MedicaidPAprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community PlanRhode Island MedicaidRIprior auth requiredMay 1, 2026Prior 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 PlanTennCareTNprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community PlanTexas CHIPTXprior auth requiredJul 1, 2021Prior 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 PlanTexas CHIPTXprior auth under conditionssite of care: outpatientJan 1, 2017Prior 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 PlanTexas STARTXprior auth under conditionssite of care: outpatientJan 1, 2015Prior 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 PlanTexas STARTXprior auth requiredJul 1, 2021Prior 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 PlanTexas STAR KidsTXprior auth under conditionssite of care: outpatientJan 1, 2017Prior 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 PlanTexas STAR KidsTXprior auth requiredJul 1, 2021Prior 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 PlanTexas STAR+PLUSTXprior auth under conditionssite of care: outpatientJan 1, 2015Prior 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 PlanTexas STAR+PLUSTXprior auth requiredJul 1, 2021Prior 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 PlanUnitedHealthcare Community Plan of FloridaFLprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of Hawaii (QUEST Integration)HIprior auth under conditionssite of care: outpatientOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of KentuckyKYprior auth under conditionssite of care: outpatientJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of KentuckyKYprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of New YorkNYprior auth requiredOct 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community PlanWashington Apple HealthWAprior auth requiredOct 1, 2026Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023
UnitedHealthcare Community PlanWisconsin BadgerCare Plus and Medicaid SSIWIprior auth requiredSep 1, 2026Prior 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 J9155

J9155 appears in 27 coverage policies from Aetna, BlueCross BlueShield of South Carolina, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaBenign Prostatic Hyperplasia (0079)not coveredApr 15, 2026payer document
AetnaGonadotropin-Releasing Hormone Analogs and Antagonists (0501)covered if criteria are metJul 10, 2026payer document
AetnaHematopoietic Cell Transplantation for Hodgkin's Disease (0495)listed, no stance (range J9000-J9999)Jul 2, 2026payer document
AetnaHematopoietic Cell Transplantation for Multiple Myeloma (0497)listed, no stance (range J9000-J9999)Aug 5, 2026payer document
AetnaHematopoietic Cell Transplantation for Selected Childhood Solid Tumors (0496)listed, no stance (range J9000-J9999)Aug 6, 2026payer document
AetnaHematopoietic Cell Transplantation for Thalassemia Major and Sickle Cell Anemia (0626)listed, no stance (range J9000-J9999)Sep 18, 2026payer document
AetnaInfusion Pumps (0161)covered if criteria are met (range J9000-J9999)Mar 31, 2026payer document
AetnaInjectable Medications (0020)listed, no stance (range J9000-J9999)Mar 5, 2026payer document
AetnaLutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) (0929)listed, no stanceJul 17, 2026payer document
AetnaMargetuximab-cmkb (Margenza) (0985)listed, no stance (range J9000-J9999)May 27, 2026payer document
AetnaNegative Pressure Wound Therapy (0334)listed, no stance (range J9000-J9999)Jun 8, 2026payer document
AetnaPertuzumab Products (0973)listed, no stance (range J9000-J9999)Apr 27, 2026payer document
AetnaPhototherapy and Photochemotherapy (PUVA) for Skin Conditions (0205)listed, no stance (range J9000-J9999)May 18, 2026payer document
AetnaRadium Ra 223 Dichloride (Xofigo) (0874)listed, no stanceDec 22, 2025payer document
AetnaRevakinagene Taroretcel-lwey (Encelto) (1079)listed, no stance (range J8501-J9999)Oct 5, 2026payer document
AetnaTumor Chemoresistance Assays (0758)listed, no stance (range J9000-J9999)Dec 2, 2025payer document
AetnaTumor Chemosensitivity Assays (0245)listed, no stance (range J9000-J9999)Apr 13, 2026payer document
BlueCross BlueShield of South CarolinaHematopoietic Cell Transplantation for Breast Cancer (CAM 80127)listed, no stance (range J9000-J9999)Jul 1, 2026payer document
BlueCross BlueShield of South CarolinaHematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults (CAM 80124)unproven / investigational (range J9000-J9999)Jul 1, 2026payer document
BlueCross BlueShield of South CarolinaHematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome (CAM 80117)listed, no stance (range J9000-J9999)Jan 1, 2026payer document
CenteneDegarelix Acetate (Firmagon) (CP.PHAR.170)covered if criteria are metNov 1, 2025payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Oncology and Supportive Care Medications (RX502.061)
Code | Generic | Brand
listed, no stanceJan 1, 2027payer document
Premera Blue CrossGonadotropin Releasing Hormone (GnRH) Analogs (5.01.625)listed, no stanceJul 14, 2026payer document
UnitedHealthcareGonadotropin Releasing Hormone Analogs (2025D0038W)listed, no stanceJul 1, 2025payer document
UnitedHealthcareGonadotropin Releasing Hormone Analogs (CS2026D0038AF)listed, no stanceJul 1, 2026payer document
UnitedHealthcareGonadotropin Releasing Hormone Analogs (for Indiana Only) (CSIND0038.07)listed, no stanceJul 1, 2025payer document
UnitedHealthcareGonadotropin Releasing Hormone Analogs (for Ohio Only) (CSOH2024D0038.A)listed, no stanceJan 1, 2024payer document

Recent prior-auth changes

  • Aug 1, 2026: PA added, Humana
  • Aug 1, 2026: PA removed, Molina Healthcare of Texas
  • Jul 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Apr 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Feb 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Jan 1, 2026: PA removed, Molina Healthcare of Michigan
  • Jan 1, 2026: PA added, UnitedHealthcare Community Plan
  • Jan 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Nov 1, 2025: PA removed, UnitedHealthcare Community Plan
  • Nov 1, 2025: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in VA.

  • AZ: $4.23 (asc), effective Oct 1, 2026
  • FL: $240.00 (physician_administered_drugs), effective Jan 1, 2026
  • IL: $4.34 (practitioner), effective Apr 1, 2026
  • IN: $5.45 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2016
  • KS: $4.51 (default), effective Oct 1, 2026
  • KY: $4.45 (asc), effective Jan 1, 2026
  • LA: $4.48 (professional), effective Jul 1, 2026
  • MS: $3.49 (comprehensive, facility), effective Oct 1, 2025
  • NE: $4.48 (injectables), effective Jul 1, 2026
  • OH: $4.48 (provider_administered_drugs), effective Jul 1, 2026
  • OK: $4.48 (physician, non-facility), effective Jul 1, 2026
  • TX: $4.45 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
  • VA: $4.48 (medical), effective Jul 1, 2026
  • VT: $3.38 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $4.48 (professional_administered_drugs), effective Jul 1, 2026
  • WY: $1.93 (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.