J9361 Inj, efbemalenograstim alfa-Injection, efbemalenograstim alfa-vuxw, 0.5 mg
J9361 payment limit: $121.429 per 0.5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
72893-0016-02 Ryzneuta, Acrotech Biopharma LLC: 40 billing units per package (1 SYRINGE in 1 CARTON / 1 mL in 1 SYRINGE)Status E: excluded from the PFS by regulation.
51 of 51 payer prior-auth lists that name J9361 require prior authorization or set conditions: Aetna, Arkansas Blue Cross and Blue Shield, Blue Cross Blue Shield of Arizona (AZ Blue), 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 New Mexico, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), UnitedHealthcare, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Arkansas Blue Cross and Blue Shield | Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime) | AR | prior auth required | Non-preferred product | Jul 1, 2024 | Medical Benefit Pharmacy Prior Approval List |
| 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 | place of service 19, 22; site of care: outpatient hospital | 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 under conditions | eviCore-delegated groups, all sites | 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 under conditions | place of service 19, 22; site of care: outpatient hospital | 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 | Step therapy applies | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) |
| Aetna | Medicare Advantage | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Commercial | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| 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 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 | Step therapy | 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 | 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 | Jan 1, 2027 | Humana Dual Fully Integrated Illinois prior authorization and notification list |
| Humana | Humana D-SNP (IN) | IN | prior auth required | Step therapy | 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 | 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 | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (VA) | VA | prior auth required | Step therapy | 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 | 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 | Step therapy | 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 Michigan | Medicaid | 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 New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| 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 |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth required | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida 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 Medicare Advantage, Peoples Health and Dual Complete (D-SNP) | All | prior auth required | Excluded plans: for therapeutic radiopharmaceuticals: UHC Nursing Home Plan and UHC Care Advantage Plan (I-SNP) | Oct 1, 2026 | UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) and OneCare | MA | prior auth required | Oct 1, 2026 | Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth under conditions | site of care: outpatient | Jul 1, 2024 | 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 | Jul 1, 2024 | 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 | Jul 1, 2024 | 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 | Jul 1, 2024 | 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 |
J9361 appears in 29 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | 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) | covered if criteria are met | 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 |
| Blue Cross & Blue Shield of Mississippi | Ryzneuta Efbemalenograstim Alfavuxw (L.5.01.626) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Ryzneuta Efbemalenograstim Alfavuxw (S.5.01.626) | not covered | 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 |
| Centene | Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim- unne (Armlupeg), Pegfilgrastim-pccg (Ennumo), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Efbemalenograstim alfa-vuxw (Ryzneuta), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca, Udenyca Autoinjector, Udenyca Onbody), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296) | covered if criteria are met | Aug 1, 2026 | payer document |
| Cigna | Colony Stimulating Factors – Ryzneuta (IP0745) | covered if criteria are met | Jan 15, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Oncology and Supportive Care Medications (RX502.061) lpuj | Faspro™ | listed, no stance | Jan 1, 2027 | payer document |
| Premera Blue Cross | Use of Granulocyte Colony-Stimulating Factors (G-CSF) (5.01.551) | listed, no stance | Sep 21, 2026 | payer document |
| UnitedHealthcare | Medicare Part B Step Therapy Programs (IAP.001.30) Non-Preferred | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (2026D0061AE) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (CS2026D0061AL) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (for Indiana Only) (CSIND0061.14) | listed, no stance | Oct 1, 2025 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (for Ohio Only) (CSOH2025D0061.D) | listed, no stance | Nov 1, 2025 | payer document |
| Wellmark Blue Cross Blue Shield | Colony Stimulating Factors (05.02.41) | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in IN, MS, VA, VT.
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.