ph-0235
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Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio™); Tbo-Filgrastim (Granix®)

Policy Number: PH-0235

 

Subcutaneous/Intravenous

 

Last Review Date: 04/01/2020

Date of Origin: 10/17/2008

Dates Reviewed: 06/2009, 12/2009, 06/2010, 07/2010, 09/2010, 12/2010, 03/2011, 6/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 04/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 04/2019, 04/2020

  1. Length of Authorization

Coverage will be provided for six months and may be renewed.

  1. Dosing Limits

A.  Quantity Limit (max daily dose) [NDC Unit]:

  • Neupogen 300 mcg vial: 3 vials per 1 day
  • Neupogen 300 mcg SingleJect: 3 syringes per 1 day
  • Neupogen 480 mcg vial: 3 vials per 1 day
  • Neupogen 480 mcg SingleJect: 3 syringes per 1 day
  • Nivestym 300 mcg vial: 3 vials per 1 day
  • Nivestym 300 mcg prefilled syringe: 3 syringes per 1 day
  • Nivestym 480 mcg vial: 3 vials per 1 day
  • Nivestym 480 mcg prefilled syringe: 3 syringes per 1 day
  • Zarxio 300 mcg prefilled syringe: 3 syringes per 1 day
  • Zarxio 480 mcg prefilled syringe: 3 syringes per 1 day
  • Granix 300 mcg pre-filled syringe: 4 syringes per 1 day
  • Granix 300 mcg single-dose vial: 4 vials per 1 day
  • Granix 480 mcg pre-filled syringe: 3 syringes per 1 day
  • Granix 480 mcg single-dose vial: 3 vials per 1 day
  1. Max Units (per dose and over time) [HCPCS Unit]:

Severe Chronic Neutropenia:

  • 1380 billable units per day

BMT or PBPC or Radiation:

  • 1200 billable units per day

All other indications:

  • 600 billable units per day
  1. Initial Approval Criteria 1-4,5,6,18-21,22-24

The patient has another FDA labeled or guideline supported (at highest level of evidence) indication.

Coverage is provided in the following conditions:

Bone marrow transplant (BMT) †/

Peripheral Blood Progenitor Cell (PBPC) mobilization and transplant 18,30,33,35-37 †/

Prophylactic use in patients with non-myeloid malignancy 1-4,5,6,8,9,11,12,14,16,27-29 †/

  • Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 20% or greater §; OR
  • Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater§ AND one or more of the following co-morbidities:
  • Elderly patients (age > 65) receiving full dose intensity chemotherapy
  • History of recurrent febrile neutropenia from chemotherapy
  • Extensive prior exposure to chemotherapy
  • Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation
  • Pre-existing neutropenia (ANC ≤ 1000/mm3)
  • Bone marrow involvement with tumor
  • Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS with low CD4 counts)
  • Recent surgery and/or open wounds
  • Poor performance status
  • Renal dysfunction (creatinine clearance <50)
  • Liver dysfunction (elevated bilirubin >2.0)
  • Chronic immunosuppression in the post-transplant setting including organ transplant

Note: Dose-dense therapy, in general, requires growth factor support to maintain dose intensity and schedule. In the palliative setting, consideration should be given to dose reduction or change in regimen.

Treatment of chemotherapy-induced febrile neutropenia 1-4,5,6,8,9,11,12,14,16,27-29

  • Patient has been on prophylactic therapy with filgrastim or tbo-filgrastim (Note: therapy should not be used concomitantly with pegfilgrastim); OR
  • Patient has not received prophylactic therapy with a granulocyte colony stimulating factor; AND
            • Patient has one or more of the following risk factors for developing infection-related complications:
      • Sepsis Syndrome
      • Age >65
      • Absolute neutrophil count [ANC] <100/mcL
      • Duration of neutropenia expected to be greater than 10 days
      • Pneumonia or other clinically documented infections
      • Invasive fungal infection
      • Hospitalization at the time of fever
      • Prior episode of febrile neutropenia

Patient who experienced a neutropenic complication from a prior cycle of the same chemotherapy 1-4,5,6,8,9,11,12,14,16,27-29

Note: Dose-dense therapy, in general, requires growth factor support to maintain dose intensity and schedule. In the palliative setting, consideration should be given to dose reduction or change in regimen.

Acute Myeloid Leukemia (AML) patient following induction or consolidation chemotherapy 1-4,7,13,35 †/

Bone Marrow Transplantation (BMT) failure or Engraftment Delay 5,6,25,26,30,33,35-37  †/‡

Severe chronic neutropenia 10 †/‡

  • Patient must have an absolute neutrophil count (ANC) < 500/mm3; AND
  • Patient must have a diagnosis of one of the following:
    • Congenital neutropenia; OR
    • Cyclic neutropenia; OR
    • Idiopathic neutropenia

Myelodysplastic Syndrome 5

  • Endogenous serum erythropoietin level of ≤500 mUnits/mL; AND
  • Patient has lower risk disease (i.e., defined as IPSS-R [Very Low, Low, Intermediate], IPSS [Low/Intermediate-1], WPSS [Very Low, Low, Intermediate]); AND
  • Used for treatment of symptomatic anemia; AND
  • Patient is receiving concurrent therapy with an Erythropoiesis Stimulating Agent (ESA)

Patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Subsyndrome of Acute Radiation Syndrome) 1-4,17 †/‡

Management of CAR T-cell related Toxicity 5

  • Patient has been receiving therapy with CAR T-cell therapy (e.g. tisangenleclecleucel (Kymriah), Axicabtagene Ciloleucel (Yescarta), etc.); AND
  • Patient is experiencing neutropenia related to their therapy.

FDA-labeled indication(s); Compendia recommended indication(s)

*Febrile neutropenia is defined as:

  • a single temperature ≥38.3 °C orally or ≥38.0 °C over 1 hour; AND
  • neutropenia: <500 neutrophils/mcL or <1,000 neutrophils/mcL and a predicted decline to ≤500 neutrophils/mcL over the next 48 hours

§ Expected incidence of febrile neutropenia percentages for myelosuppressive chemotherapy regimens can be found in the NCCN Myeloid Growth Factors Clinical Practice Guideline at NCCN.org

  1. Renewal Criteria

Coverage for all other indications can be renewed based upon the following criteria:

  • Patient continues to meet indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: splenic rupture, acute respiratory distress syndrome (ARDS), serious allergic reactions/anaphylaxis, sickle cell crisis, glomerulonephritis, leukocytosis, capillary leak syndrome, potential for tumor growth stimulation of malignant cells, aortitis, alveolar hemorrhage and hemoptysis, thrombocytopenia, cutaneous vasculitis etc.

  1. Dosage/Administration

Indication

Dose

BMT/PBPC/Radiation Indications

10 mcg/kg daily for up to 14 days

Congenital Neutropenia

6 mcg/kg twice daily

All other indications

5 mcg/kg daily for up to 14 days

  1. Billing Code/Availability Information

HCPCS Code:

  • J1442 – Injection, filgrastim (Neupogen), excludes biosimilars, 1 mcg:  1 billable unit = 1 mcg
  • Q5110 – Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 mcg: 1 billable unit = 1 mcg
  • Q5101 – Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 mcg: 1 billable unit = 1 mcg
  • J1447 – Injection, tbo-filgrastim (Granix), 1 mcg: 1 billable unit =1 mcg

NDC:

  • Neupogen 300 mcg single-dose vial: 55513-0530-xx
  • Neupogen 300 mcg single-dose prefilled syringe (SingleJect): 55513-0924-xx
  • Neupogen 480 mcg single-dose vial: 55513-0546-xx
  • Neupogen 480 mcg single-dose prefilled syringe (SingleJect): 55513-0209-xx
  • Nivestym 300 mcg vial: 00069-0293-xx
  • Nivestym 300 mcg prefilled syringe: 00069-0291-xx
  • Nivestym 480 mcg vial: 00069-0294-xx
  • Nivestym 480 mcg prefilled syringe: 00069-0292-xx
  • Zarxio 300 mcg single-dose prefilled syringe: 61314-0318-xx
  • Zarxio 480 mcg single-dose prefilled syringe: 61314-0326-xx
  • Granix 300 mcg single-dose prefilled syringe: 63459-0910-xx
  • Granix 480 mcg single-dose prefilled syringe: 63459-0912-xx
  • Granix 300 mcg single-dose vial: 63459-0918-xx
  • Granix 480 mcg single-dose vial: 63459-0920-xx
  1. References
  1. Neupogen [package insert]. Thousand Oaks, CA; Amgen Inc; June 2018. Accessed March 2020.
  2. Nivestym [package insert]. Lake Forest, IL; Hospira Inc; July 2018. Accessed March 2020.
  3. Zarxio [package insert]. Princeton, NJ; Sandoz Inc; August 2019. Accessed March 2020.
  4. Granix [package insert].  North Wales, PA; Teva Pharmaceuticals USA, Inc.; November 2019. Accessed March 2020.
  5. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) filgrastim. National Comprehensive Cancer Network, 2020.  The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org.  Accessed March 2020.
  6. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Hematopoietic Growth Factors. Version 2.2020.  National Comprehensive Cancer Network, 2020. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org.  Accessed March 2020.
  7. Heil G, Hoelzer D, Sanz MA, et al. A randomized, double-blind, placebo-controlled, phase III study of filgrastim in remission induction and consolidation therapy for adults with de novo acute myeloid leukemia. Blood. 1997;90:4710-4718.
  8. Rusthoven J, Bramwell V, Stephenson B. Use of granulocyte colony-stimulating factor (G-CSF) in patients receiving myelosuppressive chemotherapy for the treatment of cancer. Provincial Systemic Treatment Disease Site Group. Cancer Prev Control. 1998;2(4):179-190.
  9. Berghmans T, Paesmans M, Lafitte JJ, et al. Therapeutic use of granulocyte and granulocyte-macrophage colony-stimulating factors in febrile neutropenic cancer patients. A systematic review of the literature with meta-analysis. Support Care Cancer. 2002;10(3):181-188.
  10. Dale DC, Bonilla MA, Davis MW, et al. A randomized controlled phase III trial of recombinant human granulocyte colony-stimulating factor (filgrastim) for treatment of severe chronic neutropenia. Blood. 1993;81(10):2496-2502.
  11. Timmer-Bonte JN, de Boo TM, Smit HJ, et al. Prevention of chemotherapy-induced febrile neutropenia by prophylactic antibiotics plus or minus granulocyte colony-stimulating factor in small-cell lung cancer: A Dutch randomized Phase III study. J Clin Oncol. 2005;23:7974–84. doi: 10.1200/JCO.2004.00.7955.
  12. Crawford J, Ozer H, Stoller R, et al. Reduction by granulocyte colony-stimulating factor of fever and neutropenia induced by chemotherapy in patients with small-cell lung cancer. N Engl J Med. 1991;325:164–70.
  13. Lilienfeld-Toal M, Hahn-Ast C, Kirchner H, et al. A randomized comparison of immediate versus delayed application of G-CSF in induction therapy for patients with acute myeloid leukemia unfit for intensive chemotherapy. Haematologica. 2007;92:1719–1720.
  14. García-Carbonero R, Mayordomo JI, Tornamira MV, et al. Granulocyte colony-stimulating factor in the treatment of high-risk febrile neutropenia: A multicenter randomized trial. J Natl Cancer Inst. 2001;93(1):31-38.
  15. Heil G, Hoelzer D, Sanz MA, et al. A randomized, double-blind, placebo-controlled, phase III study of filgrastim in remission induction and consolidation therapy for adults with de novo acute myeloid leukemia. The International Acute Myeloid Leukemia Study Group. Blood. 1997;90(12):4710-4718.
  16. Smith TJ, Bohlke K, Lyman GH, Carson KR, Crawford J, Cross SJ, Goldberg JM, Khatcheressian JL, Leighl NB, Perkins CL, Somlo G, Wade JL, Wozniak AJ, Armitage JO. Recommendations for the use of WBC growth factors: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2015 Jul 13. pii: JCO.2015.62.3488. [Epub ahead of print]
  17. Farese AM, MacVittie TJ. Filgrastim for the treatment of hematopoietic acute radiation syndrome. Drugs Today (Barc) 2015;51:537-48.
  18. Schmitt M, Publicover A, Orchard KH, et al. Biosimilar G-CSF based mobilization of peripheral blood hematopoietic stem cells for autologous and allogeneic stem cell transplantation. Theranostics. 2014;4(3):280-289.
  19. Abraham I, Tharmarajah S, MacDonald K. Clinical safety of biosimilar recombinant human granulocyte colony-stimulating factors. Expert Opin Drug Saf. 2013;12(2):235-246.
  20. Yao HM, Ottery FD, Borema T, et al. PF-06881893 (Nivestym™), a Filgrastim Biosimilar, Versus US-Licensed Filgrastim Reference Product (US-Neupogen®): Pharmacokinetics, Pharmacodynamics, Immunogenicity, and Safety of Single or Multiple Subcutaneous Doses in Healthy Volunteers. BioDrugs. 2019 Apr;33(2):207-220.
  21. Smith TJ, Bohlke K, Lyman GH, Carson KR, Crawford J, Cross SJ, Goldberg JM, Khatcheressian JL, Leighl NB, Perkins CL, Somlo G, Wade JL, Wozniak AJ, Armitage JO. Recommendations for the use of WBC growth factors: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2015 Jul 13. pii: JCO.2015.62.3488. [Epub ahead of print]
  22. Lubenau H, Sveikata A, Gumbrevicius G, et al. Bioequivalence of two recombinant granulocyte colony-stimulating factor products after subcutaneous injection in healthy volunteers. Int J Clin Pharmacol Ther. 2009;47(4):275-282.
  23. Gascon P, Fuhr U, Sörgel F, et al. Development of a new G-CSF product based on biosimilarity assessment. Ann Oncol. 2010 Jul;21(7):1419-29.
  24. Kelaidi C Beyne-Rauzy O, Braun T, et al. High Response rate and improved exercise capacity and quality of life with a new regimen of darbepoetin alfa with or without filgrastim in lower-risk myelodysplastic syndromes: a phase II study by the GFM. Ann Hematol 2013; 92:621-631.
  25. Elayan MM, Horowitz JG, Magraner JM, Shaughnessy PJ, Bachier C. Tbo-Filgrastim versus Filgrastim during Mobilization and Neutrophil Engraftment for Autologous Stem Cell Transplantation. Biol Blood Marrow Transplant. 2015 Nov; 21(11):1921-5. doi: 10.1016/j.bbmt.2015.05.024.
  26. Trifilio S, Zhou Z, Galvin J, Fong JL, Monreal J, Mehta J. Filgrastim versus TBO-filgrastim to reduce the duration of neutropenia after autologous hematopoietic stem cell transplantation: TBO, or not TBO, that is the question. Clin Transplant. 2015 Oct 22. doi: 10.1111/ctr.12637.
  27. del Giglio A, Eniu A, Ganea-Motan D, Topuzov E, Lubenau H. XM02 is superior to placebo and equivalent to Neupogen in reducing the duration of severe neutropenia and the incidence of febrile neutropenia in cycle 1 in breast cancer patients receiving docetaxel/doxorubicin chemotherapy. BMC Cancer. 2008;8:332.
  28. Gatzemeier U, Ciuleanu T, Dediu M, et al. XM02, the first biosimilar G-CSF, is safe and effective in reducing the duration of severe neutropenia and incidence of febrile neutropenia in patients with small cell or non-small cell lung cancer receiving platinum-based chemotherapy. J Thorac Oncol. 2009;4(6):736-40.
  29. Engert A, Griskevicius L, Zyuzgin Y, Lubenau H, del Giglio A. XM02, the first granulocyte colony-stimulating factor biosimilar, is safe and effective in reducing the duration of severe neutropenia and incidence of febrile neutropenia in patients with non-Hodgkin lymphoma receiving chemotherapy. Leuk Lymphoma. 2009;50(3):374-79.
  30. Bhamidipati PK, Fiala MA, Grossman BJ, et al. Results of a prospective randomized, open-label, noninferiority study of tbo-filgrastim (Granix) versus filgrastim (Neupogen) in combination with Plerixafor for autologous stem cell mobilization in patients with multiple myeloma and non-Hodgkin lymphoma. Biol Blood Marrow Transplant. August 7, 2017
  31. Engert A, del Giglio A, Bias P, et al. Incidence of febrile neutropenia and myelotoxicity of chemotherapy: A meta-analysis of biosimilar G-CSF studies in breast cancer, lung cancer, and non-Hodgkin's lymphoma. Onkologie. 2009;32(10):599-604.
  32. Lubenau H, Bias P, Maly AK, Siegler KE, Mehltretter K. Pharmacokinetic and pharmacodynamic profile of new biosimilar filgrastim XM02 equivalent to marketed filgrastim Neupogen: Single-blind, randomized, crossover trial. BioDrugs. 2009;23(1):43-51.
  33. Andreola G, Babic A, Rabascio C, et al. Plerixafor and Filgrastim XM02 (Tevagastrim) as a first line peripheral blood stem cell mobilisation strategy in patients with multiple myeloma and lymphoma candidated to autologous bone marrow transplantation. Eur J Haematol. 2012;88(2):154-158.
  34. Bagalagel A, Mohammed A, MacDonald K, Abraham I. Clinical efficacy and safety of Tevagrastim® (XM02), a biosimilar recombinant human granulocyte colony-stimulating factor. Biosimilars. 2013;2013(3):55-62.
  35. Danylesko I, Sareli R, Bloom-Varda N, et al. The use of Tevagrastim (biosimilar filgrastim XMO2) for hematopoietic stem cell mobilization In HLA matched sibling donors for allogeneic stem cell transplantation to AML/MDS patients. Blood. 2013;122(21):3275.
  36. Schmitt M, Xu X, Hilgendorf I, et al. Mobilization of PBSC for allogeneic transplantation by the use of the G-CSF biosimilar XM02 in healthy donors. Bone Marrow Transplant. 2013;48(7):922-925
  37. Schmitt M, Hoffmann JM, Lorenz K, et al. Mobilization of autologous and allogeneic peripheral blood stem cells for transplantation in haematological malignancies using biosimilar G-CSF. Vox Sang. 2016;111(2):178-186.
  38. First Coast Service Options, Inc.  Local Coverage Article:  Billing and Coding: G-CSF Filgrastim (A57789).  Centers for Medicare & Medicaid Services, Inc.  Updated on 11/21/2019 with effective date 10/03/2018.  Accessed March 2020.
  39. National Government Services, Inc. Local Coverage Article: Billing and Coding: Filgrastim, Pegfilgrastim, Tbo-filgrastim and biosimilars - (A52408).  Centers for Medicare & Medicaid Services, Inc.  Updated on 12/20/2019 with effective date 01/01/2020.  Accessed March 2020.
  40. Palmetto GBA. Local Coverage Determination: White Cell Colony Stimulating Factors (A56748).  Centers for Medicare & Medicaid Services, Inc.  Updated on 12/10/2019 with effective date 01/01/2020.  Accessed March 2020.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

C92.00

Myeloid leukemia not having achieved remission

C92.02

Myeloid leukemia in relapse

C92.50

Acute myelomonocytic leukemia not having achieved remission

C92.52

Acute myelomonocytic leukemia in relapse

C92.60

Acute myeloid leukemia with 11q23-abnormality not having achieved remission

C92.62

Acute myeloid leukemia with 11q23-abnormality in relapse

C92.A0

Acute myeloid leukemia with multilineage dysplasia not having achieved remission

C92.A2

Acute myeloid leukemia with multilineage dysplasia in relapse

C93.00

Acute monoblastic/monocytic leukemia not having achieved remission

C93.02

Acute monoblastic/monocytic leukemia in relapse

C93.10

Chronic myelomonocytic leukemia, not having achieved remission

C94.00

Acute erythroid leukemia not having achieved remission

C94.02

Acute erythroid leukemia in relapse

C94.20

Acute megakaryoblastic leukemia not having achieved remission

C94.22

Acute megakaryoblastic leukemia in relapse

D46.0

Refractory anemia without ring sideroblasts, so stated

D46.1

Refractory anemia with ring sideroblasts

D46.20

Refractory anemia with excess of blasts, unspecified

D46.21

Refractory anemia with excess of blasts 1

D46.4

Refractory anemia, unspecified

D46.9

Myelodysplastic syndrome, unspecified

D46.A

Refractory cytopenia with multilineage dysplasia

D46.B

Refractory cytopenia with multilineage dysplasia and ring sideroblasts

D46.Z

Other myelodysplastic syndrome

D61.81

Pancytopenia

D70.0

Congenital agranulocytosis

D70.1

Agranulocytosis secondary to cancer chemotherapy

D70.2

Other drug-induced agranulocytosis

D70.4

Cyclic neutropenia

D70.9

Neutropenia, unspecified

T45.1X5A

Adverse effect of antineoplastic and immunosuppressive drugs initial encounter

T45.1X5D

Adverse effect of antineoplastic and immunosuppressive drugs subsequent encounter

T45.1X5S

Adverse effect of antineoplastic and immunosuppressive drugs sequela

T66.XXXA

Radiation sickness, unspecified, initial encounter

T66.XXXD

Radiation sickness, unspecified, subsequent encounter

T66.XXXS

Radiation sickness, unspecified, sequela

W88.1

Exposure to radioactive isotopes

W88.8

Exposure to other ionizing radiation

Z41.8

Encounter for other procedures for purposes other than remedying health state

Z48.290

Encounter for aftercare following bone marrow transplant

Z51.11

Encounter for antineoplastic chemotherapy

Z51.12

Encounter for antineoplastic immunotherapy

Z51.89

Encounter for other specified aftercare

Z52.001

Unspecified donor, stem cells

Z52.011

Autologous donor, stem cells

Z52.091

Other blood donor, stem cells

Z76.89

Persons encountering health services in other specified circumstances

Z94.81

Bone marrow transplant status

Z94.84

Stem cells transplant status

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):

Jurisdiction(s): J,M

NCD/LCD Document (s): A56748

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A56748&bc=gAAAAAAAAAAA  

Jurisdiction(s):  N

NCD/LCD Document (s): A57789

https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=A57789&bc=gAAAAAAAAAAA&  

Jurisdiction(s): 6, K

NCD/LCD Document (s): A52408

https://www.cms.gov/medicare-coverage-database/search/document-id-search-results.aspx?DocID=A52408&bc=gAAAAAAAAAAA&

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

FILGRASTIMS (Neupogen®, Nivestym™, Zarxio™ and Granix®) Prior Auth Criteria
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