Q5105 Inj retacrit esrd on dialysiInjection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units
Q5105 payment limit: $0.817 per 100 UNITS, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
00069-1305-10 Retacrit, Pfizer Inc: 200 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)00069-1306-10 Retacrit, Pfizer Inc: 300 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)00069-1307-10 Retacrit, Pfizer Inc: 400 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)00069-1308-10 Retacrit, Pfizer Inc: 1000 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)00069-1309-04 Retacrit, Pfizer Inc: 1600 billing units per package (4 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)00069-1311-10 Retacrit, Pfizer Inc: 2000 billing units per package (10 VIAL, MULTI-DOSE in 1 CARTON / 1 mL in 1 VIAL, MULTI-DOSE)00069-1318-10 Retacrit, Pfizer Inc: 1000 billing units per package (10 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE)59353-0002-10 Retacrit, Vifor (International) Inc.: 200 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)59353-0003-10 Retacrit, Vifor (International) Inc.: 300 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)59353-0004-10 Retacrit, Vifor (International) Inc.: 400 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)59353-0120-10 Retacrit, Vifor (International) Inc.: 2000 billing units per package (10 VIAL, MULTI-DOSE in 1 CARTON / 1 mL in 1 VIAL, MULTI-DOSE)59353-0220-10 Retacrit, Vifor (International) Inc.: 1000 billing units per package (10 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE)Status E: excluded from the PFS by regulation.
29 of 30 payer prior-auth lists that name Q5105 require prior authorization or set conditions: Aetna, Blue Cross and Blue Shield of Texas, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid).
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 | Jul 1, 2018 | Master Precertification List (For Health Care Providers) | |
| Cigna | Basic Standard | All | prior auth required | Jul 1, 2018 | Master Precertification List (For Health Care Providers) | |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | Jul 1, 2018 | 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 | 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 | 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 | |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 |
Q5105 appears in 11 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, BlueCross BlueShield of South Carolina, Centene, Cigna, Premera Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Erythropoiesis Stimulating Agents (0195) | covered if criteria are met | Jan 20, 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 (2026D0028Y) | listed, no stance | Apr 1, 2026 | payer document |
| UnitedHealthcare | Erythropoiesis-Stimulating Agents (CS2026D0028R) | 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 |
Prior authorization required or conditional in 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.