Summary & Overview
HCPCS J1306: Inclisiran Injection, 1 mg
HCPCS Level II code J1306 denotes the administration of inclisiran, an injectable lipid-lowering agent, dosed at 1 mg per billing unit. This code captures the drug product itself for billing in outpatient or clinic settings and is relevant nationally as novel lipid-lowering therapies expand treatment options for patients with elevated LDL cholesterol.
Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare (UHC), and Medicare. Readers will find a concise overview of coverage considerations across major payers, benchmark pricing context, and clinical-service context for where and how the drug is typically administered. The publication outlines payer coverage patterns, common billing practices tied to injectable drug codes, and policy updates affecting reimbursement pathways for specialty injectables.
The report is intended to help coding, billing, and policy staff understand the role of J1306 in claims workflows, identify where to look for payer-specific policies, and interpret national trends in utilization and coverage for inclisiran. Data not available in the input will be identified as such in the detailed sections.
Billing Code Overview
HCPCS Level II code J1306 represents an injection of inclisiran, specified as 1 mg per billing unit. The service type is an injectable medication administration used for delivering inclisiran to patients.
Typical site of service for this billing code is outpatient clinic or physician office settings where injectable lipid-lowering therapies are administered. Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is a middle-aged or older adult with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease who has persistently elevated low-density lipoprotein cholesterol (LDL-C) despite maximally tolerated statin therapy and other lipid-lowering agents. The medication J1306 (inclisiran, 1 mg) is administered as a subcutaneous injection given in a clinic, specialty infusion center, or outpatient office visit by a licensed clinician (cardiologist, lipid specialist, or nurse practitioner) trained in injectable biologics. The clinical workflow includes pre-administration verification of the patient’s indication and prior authorization status, documentation of recent lipid panel results, assessment for contraindications (including hypersensitivity), patient education on expected dosing schedule (initial dose, 3-month dose, then every 6 months), preparation of the single-use syringe per manufacturer guidance, administration in the subcutaneous tissue (commonly abdomen, thigh, or upper arm), and post-injection observation for immediate adverse reactions. Documentation includes the HCPCS code J1306, the injection site, lot number, dose administered, any applicable modifier(s), and updated LDL-C results in the medical record for ongoing monitoring.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
62 | Two surgeons |