`Q5110` Nivestym

Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram

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

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 1500 units per day (clinical), rationale: Prescribing Information
Outpatient hospital: max 1500 units per day (clinical), rationale: Prescribing Information

Medicare pricing for Q5110

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

Q5110 payment limit: $0.329 per 1 MCG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: 8% of reference add-on applied.

NDCs that bill under Q5110 (CMS ASP NDC-HCPCS crosswalk, October 2026)

00069-0291-01 Nivestym, Pfizer Inc: 300 billing units per package (1 SYRINGE in 1 CARTON / .5 mL in 1 SYRINGE)
00069-0291-10 Nivestym, Pfizer Inc: 3000 billing units per package (10 CARTON in 1 CARTON / 1 SYRINGE in 1 CARTON / .5 mL in 1 SYRINGE)
00069-0292-01 Nivestym, Pfizer Inc: 480 billing units per package (1 SYRINGE in 1 CARTON / .8 mL in 1 SYRINGE)
00069-0292-10 Nivestym, Pfizer Inc: 4800 billing units per package (10 CARTON in 1 CARTON / 1 SYRINGE in 1 CARTON / .8 mL in 1 SYRINGE)
00069-0293-10 Nivestym, Pfizer Inc: 3000 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-DOSE)
00069-0294-10 Nivestym, Pfizer Inc: 4800 billing units per package (10 VIAL, SINGLE-DOSE in 1 CARTON / 1.6 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 Q5110

140 of 148 payer prior-auth lists that name Q5110 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 Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, HealthSpring, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Ohio, Neighborhood Health Partnership, Oxford Health Plans, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.

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		Jan 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	Non-oncology dx: AZ Blue	Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required	Oncology dx: eviCore	Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Federal Employee Program (FEP)	AZ	prior auth required		Sep 1, 2026	Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 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		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	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)
Blue Cross and Blue Shield of Illinois	Blue Cross Community Health Plans (BCCHP), Illinois Medicaid	IL	prior auth required	Carelon-managed	Aug 1, 2025	Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of Illinois	Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)	IL	prior auth required		Jan 1, 2025	Procedure Code List, Effective 1/1/2025
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)
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	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	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 Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
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
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth under conditions	site of care: outpatient	Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth under conditions	site of care: outpatient	Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Neighborhood Health Partnership	Neighborhood Health Partnership	FL	prior auth under conditions	2 For some codes, prior authorization is required for both oncology and non-oncology Dx.. For oncology Dx, please see Cancer supportive care section above. For non-oncology Dx submit online using the	Sep 1, 2026	Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth under conditions	2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior	Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
Surest	Surest health plans	All	prior auth under conditions	*Codes J1442, J1447,	Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
Surest	Surest health plans	All	prior auth required		Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 2026
Surest	Surest health plans	All	prior auth under conditions	2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior	Oct 1, 2026	Prior Authorization Requirements for Surest Effective October 1, 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	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	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth under conditions	*Codes	Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth under conditions	2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Commercial	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare commercial plans 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 Complete (Individual & Family plans)	All	prior auth under conditions	site of care: outpatient	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth under conditions	site of care: outpatient	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 Individual Exchange plans	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth under conditions	site of care: outpatient	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	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth under conditions	2 Some codes may require prior authorization for both oncology and non- oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prio	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Mid-Atlantic Health Plans	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare of the River Valley	All	prior auth under conditions	2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026
UnitedHealthcare Community Plan	AHCCCS Complete Care (ACC)	AZ	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026
UnitedHealthcare Community Plan	ALTCS Developmentally Disabled	AZ	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana Hoosier Care Connect	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana PathWays for Aging (MLTSS)	IN	prior auth required		Oct 1, 2026	Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth required		Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth under conditions	site of care: outpatient	Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Louisiana Medicaid (Healthy Louisiana)	LA	prior auth under conditions	site of care: outpatient	Jan 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	site of care: outpatient	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026

Payer coverage policies that name Q5110

Q5110 appears in 14 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Donor Lymphocyte Infusion (0638)	not covered	Sep 29, 2026	payer document
Aetna	Hematopoietic Colony-Stimulating Factors (CSFs) (0055)	covered if criteria are met	Jul 16, 2026	payer document
Aetna	Lurbinectedin (Zepzelca) (0978)	listed, no stance	Mar 11, 2026	payer document
Aetna	Motixafortide (Aphexda) (1046)	listed, no stance	Dec 11, 2025	payer document
Aetna	Plerixafor (0779)	listed, no stance	Feb 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Biosimilar Medications (S.5.01.593)	listed, no stance		payer document
Blue Cross & Blue Shield of Mississippi	Biosimilar Medications (L.5.01.593)	listed, no stance		payer document
Centene	Filgrastim (Neupogen), Filgrastim-sndz (Zarxio), Tbo- filgrastim (Granix), Filgrastim-aafi (Nivestym), Filgrastim-ayow (Releuko), Filgrastim-txid (Nypozi), Filgrastim-laha (Filkri) (CP.PHAR.297)	covered if criteria are met	Aug 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Oncology and Supportive Care Medications (RX502.061) oysk \| Hycleta™	listed, no stance	Jan 1, 2027	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 (CS2026D0061AL)	listed, no stance	Sep 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 (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

Recent prior-auth changes

Oct 14, 2026: PA removed, Humana
Sep 1, 2026: conditions changed, Oxford Health Plans
Jul 1, 2026: conditions changed, CarePlus Health Plans
Jul 1, 2026: conditions changed, Oxford Health Plans
Jun 1, 2026: conditions changed, UnitedHealthcare
May 1, 2026: conditions changed, UnitedHealthcare
Apr 1, 2026: conditions changed, UnitedHealthcare
Apr 1, 2026: conditions changed, UnitedHealthcare Community Plan
Apr 1, 2026: conditions changed, Surest
Apr 1, 2026: conditions changed, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in IN, VA.

AZ: $0.27 (asc), effective Oct 1, 2026
FL: $1500.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $0.28 (practitioner), effective Apr 1, 2026
IN: $0.65 (professional, Advanced Practice Nurse (85%), non-facility), effective Jul 1, 2024
KS: $0.33 (asc, facility), effective Oct 1, 2026
KY: $28.00 (asc), effective Jan 1, 2026
MS: $0.23 (comprehensive, facility), effective Oct 1, 2025
NE: $0.32 (injectables), effective Jul 1, 2026
OH: $0.28 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.32 (physician, non-facility), effective Jul 1, 2026
TX: $0.28 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $0.31 (medical), effective Jul 1, 2026
VT: $0.23 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $0.32 (professional_administered_drugs), effective Jul 1, 2026
WY: $0.12 (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.

Q5110 Nivestym