MedicaidCoverageMedium impact
BT202597: Coverage added for inhaled agent for cystic fibrosis Pulmozyme (J7639) under the IHCP medical benefit
Indiana Medicaid (IHCP)·IN · Pulmonology, Infectious Disease, Pediatrics·Medical Policy
Effective date
Aug 1, 2025
We identified it
Jun 18, 2026
Summary
Indiana Health Coverage Programs (IHCP) is adding coverage for Pulmozyme (dornase alfa) under the medical benefit effective August 1, 2025, using HCPCS code J7639. This inhaled medication for cystic fibrosis will require prior authorization with the same criteria as the existing pharmacy benefit, including age 5+ and prescription by a specialist.
Action Required
By August 1, 2025: Billing team must update system to include HCPCS code J7639 for Pulmozyme with prior authorization requirement and NDC code requirement. Set maximum fee at $56.19. Ensure providers prescribing for cystic fibrosis patients age 5+ obtain prior authorization through pulmonologist, infectious disease specialist, or cystic fibrosis specialist. Update billing software to require NDC codes for all J7639 claims or they will be rejected.