`Q4081` Epoetin alfa, 100 units esrd

Injection, epoetin alfa, 100 units (for esrd on dialysis)

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 100 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 400 units per day (clinical), rationale: Clinical: Data

Medicare pricing for Q4081

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

Q4081 payment limit: $0.667 per 100 UNITS, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under Q4081 (CMS ASP NDC-HCPCS crosswalk, October 2026)

55513-0126-10 Epogen, Amgen Inc: 200 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0126-20 Epogen, Amgen Inc: 200 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0144-10 Epogen, Amgen Inc: 1000 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0148-10 Epogen, Amgen Inc: 400 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0267-10 Epogen, Amgen Inc: 300 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0267-20 Epogen, Amgen Inc: 300 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0283-10 Epogen, Amgen Inc: 2000 billing units per package (10 VIAL in 1 PACKAGE / 2 mL in 1 VIAL)
55513-0283-20 Epogen, Amgen Inc: 2000 billing units per package (10 VIAL in 1 PACKAGE / 2 mL in 1 VIAL)
55513-0478-10 Epogen, Amgen Inc: 2000 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
55513-0478-20 Epogen, Amgen Inc: 2000 billing units per package (10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL)
59676-0302-01 Procrit, Janssen Products, LP: 120 billing units per package (6 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)
59676-0303-01 Procrit, Janssen Products, LP: 180 billing units per package (6 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)
59676-0304-01 Procrit, Janssen Products, LP: 240 billing units per package (6 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)
59676-0310-01 Procrit, Janssen Products, LP: 600 billing units per package (6 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)
59676-0310-02 Procrit, Janssen Products, LP: 2500 billing units per package (25 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)
59676-0312-04 Procrit, Janssen Products, LP: 800 billing units per package (4 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE)
59676-0320-04 Procrit, Janssen Products, LP: 800 billing units per package (4 VIAL, MULTI-DOSE in 1 CARTON / 1 mL in 1 VIAL, MULTI-DOSE)
59676-0340-01 Procrit, Janssen Products, LP: 1600 billing units per package (4 VIAL, SINGLE-DOSE in 1 CARTON / 1 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 Q4081

22 of 23 payer prior-auth lists that name Q4081 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Cigna, Humana, Molina Healthcare of Texas.

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	Step therapy	Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Aetna	Medicare Advantage	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required	Step therapy applies	Aug 25, 2026	Aetna Medicare Part B drug list (partbname.xml)
Aetna	Commercial	All	prior auth required		Oct 1, 2026	Participating provider precertification list for Aetna®
Cigna	ACA/IFP	All	prior auth required		Feb 16, 2015	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required		Feb 16, 2015	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required		Feb 16, 2015	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	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
Humana	Humana Healthy Horizons	FL	prior auth required	NDC required	Jan 1, 2027	Humana Healthy Horizons in Florida Prior Authorization and Notification List
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	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
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	LA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Louisiana 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	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	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	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
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19

Payer coverage policies that name Q4081

Q4081 appears in 17 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Centene, Cigna, Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Acute Ischemic Stroke Treatments (0789) Cerebrolysin, Transdermal glyceryl trinitrate, Statins (e.g. simvastatin)	not covered	Nov 19, 2025	payer document
Aetna	Diabetic Neuropathy: Selected Treatments (0729) Fulranumab, Ozone Therapy, Ghrelin, Interleukin - 6, mecobalamin (a vitamin B12 analog), pulsed magnetic field treatment	not covered	Feb 24, 2026	payer document
Aetna	Erythropoiesis Stimulating Agents (0195)	covered if criteria are met	Jan 20, 2026	payer document
Aetna	Hypoxic Ischemic Encephalopathy (0812) Topiramate	not covered	Nov 20, 2025	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range Q4081-Q4086)	Mar 5, 2026	payer document
Aetna	Intravenous Iron Therapy (0575)	listed, no stance	Jul 1, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Erythropoiesisstimulating Agents (S.5.01.423)	listed, no stance		payer document
Blue Cross & Blue Shield of Mississippi	Erythropoiesisstimulating Agents (L.5.01.423)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Erythopoiesis Stimulating Agents and Darbepoetin Alfa (Aranesp) (CAM 50104)	listed, no stance	Jan 1, 2026	payer document
Centene	Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit) Reference Number: CP.PHAR.237 (CP.PHAR.237)	covered if criteria are met	May 1, 2026	payer document
Cigna	Erythropoiesis-Stimulating Agents – Epoetin Alfa Products (IP0296)	covered if criteria are met	Sep 1, 2026	payer document
Premera Blue Cross	Erythropoiesis-Stimulating Agents (5.01.535)	listed, no stance	Jun 8, 2026	payer document
UnitedHealthcare	Erythropoiesis-Stimulating Agents (CS2026D0028R)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Erythropoiesis-Stimulating Agents (2026D0028Y)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Erythropoiesis-Stimulating Agents (for Indiana Only) (CSIND0028.06)	listed, no stance	Apr 1, 2025	payer document
UnitedHealthcare	Erythropoiesis-Stimulating Agents (for Ohio Only) (CSOH2026D0028.C)	listed, no stance	Mar 1, 2026	payer document
Wellmark Blue Cross Blue Shield	Erythropoiesis Stimulating Agents (05.04.25)	listed, no stance	Jan 1, 2026	payer document

Recent prior-auth changes

Oct 14, 2026: PA removed, Humana
Feb 19, 2025: PA added, Molina Healthcare of Texas
Feb 19, 2025: PA added, Molina Healthcare of Texas
Feb 19, 2025: PA added, Molina Healthcare of Texas
Feb 19, 2025: PA added, Molina Healthcare of Texas
Jan 1, 2025: PA removed, UnitedHealthcare
Jun 1, 2023: PA removed, Blue Shield of California Promise Health Plan
Sep 1, 2022: PA added, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

AZ: $0.69 (outpatient_hospital), effective Jul 1, 2026
FL: $100.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $0.71 (practitioner), effective Apr 1, 2026
IN: $1.48 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2017
KS: $0.67 (default), effective Oct 1, 2026
MS: $0.73 (comprehensive), effective Jul 1, 2026
NE: $0.68 (injectables), effective Jul 1, 2026
OH: $0.73 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.69 (physician, non-facility), effective Jul 1, 2026
TX: $0.71 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Mar 1, 2026
VA: $0.68 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $0.69 (kidneycenters), 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.

Q4081 Epoetin alfa, 100 units esrd