Q5111 Injection, udenyca 0.5 mg

Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg

Medically Unlikely Edits (effective October 1, 2026)

Medicare pricing for Q5111

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

Q5111 payment limit: $128.967 per 0.5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: AMP-based payment limit.

NDCs that bill under Q5111 (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 Q5111

180 of 180 payer prior-auth lists that name Q5111 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, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, 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, and others.

PayerPlanStatePrior authConditionsSinceSource
Arkansas Blue Cross and Blue ShieldDrugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime)ARprior auth requiredNon-preferred productJan 1, 2024Medical Benefit Pharmacy Prior Approval List
Blue Cross Blue Shield of Arizona (AZ Blue)AZ Blue-administered Medicare Advantage (M2K)AZprior auth requiredOncology dx: eviCoreSep 1, 2026AZ 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)AZprior auth requiredNon-oncology dx: AZ BlueSep 1, 2026AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)Federal Employee Program (FEP)AZprior auth requiredSep 1, 2026Federal 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)AZprior auth under conditionsplace of service 19, 22; site of care: outpatient hospitalSep 1, 2026AZ 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)AZprior auth under conditionseviCore-delegated groups, all sitesSep 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 Cross Blue Shield of Arizona (AZ Blue)Teamsters group (TYW)AZprior auth under conditionsplace of service 19, 22; site of care: outpatient hospitalSep 1, 2026Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026)
Blue Shield of California Promise Health PlanPromise Health Plan Medi-CalCAprior auth requiredSep 1, 2026Medi-Cal Prior Authorization List
AetnaMedicare AdvantageAllprior auth requiredStep therapy appliesAug 25, 2026Aetna Medicare Part B drug list (partbname.xml)
AetnaMedicare AdvantageAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
AetnaCommercialAllprior auth requiredOct 1, 2026Participating provider precertification list for Aetna®
CignaACA/IFPAllprior auth requiredMay be delegated to eviCore for some clientsJan 1, 2019Master Precertification List (For Health Care Providers)
CignaBasic StandardAllprior auth requiredMay be delegated to eviCore for some clientsJan 1, 2019Master Precertification List (For Health Care Providers)
CignaComplete/PHS+/PreferredAllprior auth requiredMay be delegated to eviCore for some clientsJan 1, 2019Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of IllinoisBlue Cross Community Health Plans (BCCHP), Illinois MedicaidILprior auth requiredCarelon-managedAug 1, 2025Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
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
CarePlus Health PlansCarePlus Health PlansFLprior auth requiredNDC requiredJan 1, 2027Medicare 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
CarePlus Health PlansCarePlus Health PlansFLprior auth requiredNDC requiredJan 1, 2027Medicare 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
CarePlus Health PlansCarePlus Health PlansFLprior auth requiredNDC requiredJan 1, 2027Medicare 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
HumanaHumana D-SNP (FL)FLprior auth requiredNDC requiredJul 1, 2026H1036-280 Humana Fully Integrated Florida prior authorization and notification list
HumanaHumana D-SNP (FL)FLprior auth requiredNDC requiredJul 1, 2026H1036-280 Humana Fully Integrated Florida prior authorization and notification list
HumanaHumana D-SNP (FL)FLprior auth requiredNDC requiredJul 1, 2026H1036-280 Humana Fully Integrated Florida prior authorization and notification list
HumanaHumana D-SNP (IL)ILprior auth requiredNDC requiredJan 1, 2027Humana Dual Fully Integrated Illinois prior authorization and notification list
HumanaHumana D-SNP (IL)ILprior auth requiredNDC requiredJan 1, 2027Humana Dual Fully Integrated Illinois prior authorization and notification list
HumanaHumana D-SNP (IL)ILprior auth requiredNDC requiredJan 1, 2027Humana Dual Fully Integrated Illinois prior authorization and notification list
HumanaHumana D-SNP (IN)INprior auth requiredNDC requiredJan 1, 2027Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
HumanaHumana D-SNP (IN)INprior auth requiredNDC requiredJan 1, 2027Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
HumanaHumana D-SNP (IN)INprior auth requiredNDC requiredJan 1, 2027Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
HumanaHumana D-SNP (MI)MIprior auth requiredNDC requiredOct 14, 2026Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
HumanaHumana D-SNP (MI)MIprior auth requiredNDC requiredOct 14, 2026Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
HumanaHumana D-SNP (MI)MIprior auth requiredNDC requiredOct 14, 2026Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
HumanaHumana D-SNP (SC)SCprior auth requiredNDC requiredJul 1, 2026Humana Dual Integrated South Carolina prior authorization and notification list
HumanaHumana D-SNP (SC)SCprior auth requiredNDC requiredJul 1, 2026Humana Dual Integrated South Carolina prior authorization and notification list
HumanaHumana D-SNP (SC)SCprior auth requiredNDC requiredJul 1, 2026Humana Dual Integrated South Carolina prior authorization and notification list
HumanaHumana D-SNP (VA)VAprior auth requiredNDC requiredJul 1, 2026Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
HumanaHumana D-SNP (VA)VAprior auth requiredNDC requiredJul 1, 2026Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
HumanaHumana D-SNP (VA)VAprior auth requiredNDC requiredJul 1, 2026Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
HumanaHumana Healthy HorizonsFLprior auth requiredNDC requiredJan 1, 2027Humana Healthy Horizons in Florida Prior Authorization and Notification List
HumanaHumana Healthy HorizonsFLprior auth requiredNDC requiredJan 1, 2027Humana Healthy Horizons in Florida Prior Authorization and Notification List
HumanaHumana Healthy HorizonsFLprior auth requiredNDC requiredJan 1, 2027Humana Healthy Horizons in Florida Prior Authorization and Notification List
HumanaHumana Healthy HorizonsKYprior auth requiredNDC requiredOct 7, 2026Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
HumanaHumana Healthy HorizonsKYprior auth requiredNDC requiredOct 7, 2026Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
HumanaHumana Healthy HorizonsKYprior auth requiredNDC requiredOct 7, 2026Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
HumanaHumana Healthy HorizonsLAprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
HumanaHumana Healthy HorizonsLAprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
HumanaHumana Healthy HorizonsLAprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Louisiana Prior Authorization and Notification List
HumanaHumana Healthy HorizonsOHprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Ohio prior authorization and notification List
HumanaHumana Healthy HorizonsOHprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Ohio prior authorization and notification List
HumanaHumana Healthy HorizonsOHprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Ohio prior authorization and notification List
HumanaHumana Healthy HorizonsSCprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in South Carolina prior authorization and notification list
HumanaHumana Healthy HorizonsSCprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in South Carolina prior authorization and notification list
HumanaHumana Healthy HorizonsSCprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in South Carolina prior authorization and notification list
HumanaHumana Healthy HorizonsVAprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
HumanaHumana Healthy HorizonsVAprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
HumanaHumana Healthy HorizonsVAprior auth requiredNDC requiredOct 14, 2026Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
HumanaHumana MA and D-SNPAllprior auth requiredNDC requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
HumanaHumana MA and D-SNPAllprior auth requiredNDC requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
HumanaHumana MA and D-SNPAllprior auth requiredNDC requiredJan 1, 2027Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
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 CaliforniaMedicaidCAprior auth requiredApr 1, 2026Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of CaliforniaMedicare AdvantageCAprior auth requiredJul 1, 2021Medicare Prior Auth (PA) Code Matrix (California), effective Q3 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 requiredJan 1, 2022Molina 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 MichiganMedicaidMIprior 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 New MexicoMedicaidNMprior auth requiredJul 1, 2026New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
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 UtahMedicaidUTprior auth requiredJan 1, 2025Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Molina Healthcare of WisconsinMedicare AdvantageWIprior auth requiredOct 1, 2021Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021

Payer coverage policies that name Q5111

Q5111 appears in 20 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.

PayerPolicyRole in policyReviewedDocument
AetnaHematopoietic Colony-Stimulating Factors (CSFs) (0055)covered if criteria are metJul 16, 2026payer document
AetnaLurbinectedin (Zepzelca) (0978)listed, no stanceMar 11, 2026payer document
AetnaPlerixafor (0779)listed, no stanceFeb 13, 2026payer document
Blue Cross & Blue Shield of MississippiBiosimilar Medications (S.5.01.593)listed, no stancepayer document
Blue Cross & Blue Shield of MississippiBiosimilar Medications (L.5.01.593)listed, no stancepayer document
BlueCross BlueShield of South CarolinaHematopoietic Colony-Stimulating Factors (CSFs) (CAM 197)
Q5101-ZA | Injection, filgrastim (G-CSF), biosimilar, 1 microgram [Zarxio]
listed, no stanceJun 1, 2026payer document
CentenePegfilgrastim (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 metAug 1, 2026payer document
CignaColony Stimulating Factors – Pegfilgrastim Products (IP0070)covered if criteria are metMar 1, 2026payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)Oncology and Supportive Care Medications (RX502.061)
tqjs | Hybreza™
listed, no stanceJan 1, 2027payer document
Premera Blue CrossUse of Granulocyte Colony-Stimulating Factors (G-CSF) (5.01.551)listed, no stanceSep 21, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (CS2026D0034AV)listed, no stanceAug 1, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (2026D0034AU)listed, no stanceAug 1, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (for Ohio Only) (CSOH2026D0034.K)listed, no stanceMay 1, 2026payer document
UnitedHealthcareMaximum Dosage and Frequency (for Pennsylvania Only) (CSPA2026D0034AS)listed, no stanceMay 1, 2026payer document
UnitedHealthcareMedicare Part B Step Therapy Programs (IAP.001.30)
Preferred
listed, no stanceJul 1, 2026payer document
UnitedHealthcareWhite Blood Cell Colony Stimulating Factors (CS2026D0061AL)listed, no stanceSep 1, 2026payer document
UnitedHealthcareWhite Blood Cell Colony Stimulating Factors (2026D0061AE)listed, no stanceSep 1, 2026payer document
UnitedHealthcareWhite Blood Cell Colony Stimulating Factors (for Indiana Only) (CSIND0061.14)listed, no stanceOct 1, 2025payer document
UnitedHealthcareWhite Blood Cell Colony Stimulating Factors (for Ohio Only) (CSOH2025D0061.D)listed, no stanceNov 1, 2025payer document
Wellmark Blue Cross Blue ShieldColony Stimulating Factors (05.02.41)listed, no stanceJun 1, 2026payer document

Recent prior-auth changes

  • Oct 14, 2026: PA removed, Humana
  • Sep 1, 2026: conditions changed, Oxford Health Plans
  • Aug 1, 2026: PA removed, Molina Healthcare of Texas
  • Jul 1, 2026: conditions changed, Oxford Health Plans
  • Jun 1, 2026: conditions changed, UnitedHealthcare
  • Jun 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • May 1, 2026: conditions changed, UnitedHealthcare
  • Apr 1, 2026: conditions changed, Surest
  • Apr 1, 2026: conditions changed, UnitedHealthcare Community Plan
  • Apr 1, 2026: conditions changed, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in CO, IN, MS, VA, VT, WA.

  • AZ: $153.89 (asc), effective Oct 1, 2026
  • FL: $12.00 (physician_administered_drugs), effective Jan 1, 2026
  • IL: $135.89 (practitioner), effective Apr 1, 2026
  • IN: $310.51 (professional, Advanced Practice Nurse (85%), non-facility), effective Jul 1, 2024
  • KS: $128.97 (asc, facility), effective Oct 1, 2026
  • KY: $161.99 (asc), effective Jan 1, 2026
  • MS: $108.83 (comprehensive, facility), effective Oct 1, 2025
  • NE: $149.13 (injectables), effective Jul 1, 2026
  • OH: $149.13 (provider_administered_drugs), effective Jul 1, 2026
  • OK: $149.13 (physician, non-facility), effective Jul 1, 2026
  • TX: $161.99 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
  • VA: $149.13 (medical), effective Jul 1, 2026
  • VT: $80.81 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $149.13 (professional_administered_drugs), effective Jul 1, 2026
  • WY: $58.82 (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.