vp-0322
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Rituxan Hycela™ (rituximab and hyaluronidase human) (Subcutaneous)

Policy Number: VP-0322

Last Review Date: 09/01/2020

Date of Origin: 7/20/2010

Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 05/2011, 06/2011, 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, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 10/2016, 02/2017, 05/2017, 08/2017, 10/2017, 02/2018, 05/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 12/2019, 03/2020, 06/2020, 09/2020

I. Length of Authorization 

Coverage will be provided for 6 months and may be renewed unless otherwise specified.

  • Maintenance therapy for mantle cell lymphoma may be renewed until disease progression or intolerable toxicity.
  • Maintenance therapy for all other indications may be renewed for up to a maximum of 2 years.

II. Dosing Limits

  1. Quantity Limit (max daily dose) [NDC Unit]:
  • Rituxan Hycela 1,400 mg/23,400 Units per 11.7 mL single-dose vial:

4 vials per 28 day supply

  • Rituxan Hycela 1,600 mg/26,800 Units per 13.4 mL single-dose vial:

1 vial per 28 day supply

  1. Max Units (per dose and over time) [HCPCS Unit]:

Follicular Lymphoma (FL):

Relapsed-Refractory

  • 1,400 mg/23,400 U (140 billable units) weekly up to 7 doses

Previously Untreated

  • 1,400 mg/23,400 U (140 billable units) every 21 days x 7 doses
  • 1,400 mg/23,400 U (140 billable units) every 8 weeks x 12 doses (maintenance)

Non-progressing after first line CVP chemotherapy

  • 1,400 mg/23,400 U (140 billable units) weekly x 3 doses at 6 month intervals (up to a maximum of 15 doses).

Diffuse Large B-Cell Lymphoma (DLBCL):

  • 1,400 mg/23,400 U (140 billable units) every 14 or 21 days x 7 doses

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL):

  • 1,600 mg/26,800 U (160 billable units) every 28 days x 5 doses

Other indications:

  • 1,400 mg/23,400 U (140 billable units) weekly for 3-7 doses in a 6-month period; OR
  • 1,400 mg/23,400 U (140 billable units) every 8 weeks (maintenance treatment)

III. Initial Approval Criteria 

Coverage is provided in the following conditions:

  •  Ruxience (rituxumab-pvvr) is the preferred product. Patient must have tried and had an inadequate response or intolerance to, or a contraindication to Ruxience, attributable to the biosimilar formulation, prior to consideration of a non-preferred rituximab product including Rituxan Hycela (rituximab/hyaluronidase human) OR Patient is continuing treatment with a non-preferred rituximab product including Rituxan Hycela; AND
  • Patient age is at least 18 years of age; AND

Universal Criteria

  • Patient does not have a severe, active infection; AND
  • Patient has been screened for the presence of hepatitis B virus (HBV) infection (i.e., HBsAg and anti-HBc) prior to initiating therapy and patients with evidence of current or prior HBV infection will be monitored for HBV reactivation during treatment; AND
  • Patient is CD20 antigen expression positive; AND
  • Patient has received at least one full dose of a rituximab product by intravenous infusion prior to initiating therapy; AND
  • Rituxan Hycela will not be used with intravenous chemotherapy agents; AND

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)* † Ф

B-Cell Lymphomas* † ‡

  • Follicular Lymphoma (FL) † Ф
  • Diffuse Large B-Cell Lymphoma (DLBCL) † Ф
  • High Grade B-Cell Lymphomas ‡
  • Castleman’s Disease ‡
  • Gastric & Non-gastric MALT Lymphoma ‡
  • Mantle Cell Lymphoma ‡
  • Nodal & Splenic Marginal Zone Lymphoma ‡
  • Histologic transformation of Nodal Marginal Zone Lymphoma to Diffuse Large B-Cell Lymphoma ‡
  • Post-transplant lymphoproliferative disorder (PTLD) ‡

Hairy Cell Leukemia ‡

Primary Cutaneous B-Cell Lymphoma ‡

*Note: Patient must meet relevant initial criteria and receive at least ONE dose of the intravenous formulation of rituximab prior to initiating therapy with the subcutaneous formulation. This substitution CANNOT be made for intravenous rituximab when used in combination with ibritumomab tiuxetan.

† FDA-labeled indication(s); ‡ Compendia recommended indication(s); Ф Orphan Drug

IV. Renewal Criteria 

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet universal and other 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 the following: severe hypersensitivity or other administration reactions (i.e. local cutaneous reactions), tumor lysis syndrome (TLS), severe mucocutaneous reactions, progressive multifocal leukoencephalopathy (PML), hepatitis B virus reactivation, serious bacterial, fungal, or viral infections, cardiac adverse reactions, renal toxicity, bowel obstruction or perforation, etc.; AND
  • Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread; AND
  • Patient has not exceeded dosing or duration limits as defined in Sections I, II, and V

V. Dosage/Administration 

Indication

Dose

Follicular Lymphoma (FL)

1,400 mg/23,400 Units subcutaneously, at a fixed dose, irrespective of patient’s BSA, according to the following schedules:

Relapsed or Refractory

  • Administer once weekly for 3 or 7 weeks following a full dose of a rituximab IV product at week 1 (i.e., 4 or 8 weeks in total)

Retreatment for Relapsed or Refractory

  • Administer once weekly for 3 weeks following a full dose of a rituximab IV product at week 1  (i.e., 4 weeks in total)

Previously Untreated

  • Administer on Day 1 of Cycles 2–8 of chemotherapy (every 21 days), for up to 7 cycles following a full dose of a rituximab IV product on day 1 of cycle 1 (i.e., up to 8 cycles in total). In patients with complete or partial response, initiate maintenance treatment 8 weeks following completion of initial therapy as a single agent every 8 weeks for 12 doses.

Non-progressing after first line CVP chemotherapy

  • Following completion of 6–8 cycles of CVP chemotherapy and a full dose of a rituximab IV product at week 1, administer once weekly for 3 weeks (i.e., 4 weeks in total) at 6 month intervals to a maximum of 16 doses.

Diffuse Large B-Cell Lymphoma (DLBCL)

1,400 mg/23,400 Units subcutaneously, at a fixed dose, irrespective of patient’s BSA.

  • Administer on Day 1 of Cycles 2–8 of chemotherapy for up to 7 cycles (i.e., up to 6-8 cycles in total). Cycle length is either 14 or 21 days.

CLL/SLL

1,600 mg/26,800 Units subcutaneously, at a fixed dose, irrespective of patient’s BSA.

  • Administer on Day 1 of Cycles 2–6 (every 28 days) for a total of 5 cycles (i.e., 6 cycles in total). Cycle length is 28 days.

All other indications

1,400 mg/23,400 Units subcutaneously, at a fixed dose, irrespective of patient’s BSA.

  • Administer up to once weekly for 3-7 doses in a 6-month period; OR
  • Administer once every 8 weeks (maintenance treatment)

Note: Patient must receive at least ONE dose of the intravenous formulation of rituximab prior to initiating therapy with the subcutaneous formulation. (This substitution CANNOT be made for intravenous rituximab when used in combination with ibritumomab tiuxetan). Must be administered by a healthcare provider.

VI. Billing Code/Availability Information

HCPCS Code:

  • J9311 – Injection, rituximab 10 mg and hyaluronidase: 1 billable unit = 10 mg

NDC:

  • Rituxan Hycela 1,400 mg rituximab/23,400 Units hyaluronidase human single-dose vial: 50242-0108-xx
  • Rituxan Hycela 1,600 mg rituximab/26,800 Units hyaluronidase human single-dose vial : 50242-0109-xx

VII. References

  1. Rituxan Hycela [package insert]. South San Francisco, CA; Genentech, Inc; May 2020. Accessed August 2020.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) rituximab and hyaluronidase human. 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 July 2020.
  3. Davies A, Merli F, Mihaljević B, et al. Efficacy and safety of subcutaneous rituximab versus intravenous rituximab for first-line treatment of follicular lymphoma (SABRINA): a randomised, open-label, phase 3 trial. Lancet Haematol. 2017 Jun;4(6):e272-e282. doi: 10.1016/S2352-3026(17)30078-9. Epub 2017 May 2.
  4. Lugtenburg P, Avivi I, Berenschot H, et al. Efficacy and safety of subcutaneous and intravenous rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone in first-line diffuse large B-cell lymphoma: the randomized MabEase study. Haematologica. 2017 Nov;102(11):1913-1922. doi: 10.3324/haematol.2017.173583. Epub 2017 Sep 21.
  5. Assouline S, Buccheri V, Delmer A, et al. Pharmacokinetics, safety, and efficacy of subcutaneous versus intravenous rituximab plus chemotherapy as treatment for chronic lymphocytic leukaemia (SAWYER): a phase 1b, open-label, randomised controlled non-inferiority trial. Lancet Haematol. 2016 Mar;3(3):e128-38. doi:10.1016/S2352-3026(16)00004-1.
  6. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for B-Cell Lymphomas Version 4.2020. National Comprehensive Cancer Network, 2020. 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 Guidelines, go online to NCCN.org. Accessed August 2020.
  7. National Government Services, Inc. Local Coverage Article: Billing and Coding: Rituximab, biosimilars and Rituximab and hyaluronidase human (Rituxan Hycela™) (A52452). Centers for Medicare & Medicaid Services, Inc. Updated on 07/24/2020 with effective date of 08/01/2020. Accessed August 2020.
  8. Palmetto GBA. Local Coverage Article: Billing and Coding: Rituximab (A56380). Centers for Medicare & Medicaid Services, Inc. Updated on 01/29/2020 with effective date of 02/06/2020. Accessed August 2020.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

C82.00

Follicular lymphoma grade I, unspecified site

C82.01

Follicular lymphoma grade I, lymph nodes of head, face and neck

C82.02

Follicular lymphoma, grade I, intrathoracic lymph nodes

C82.03

Follicular lymphoma grade I, intra-abdominal lymph nodes

C82.04

Follicular lymphoma grade I, lymph nodes of axilla and upper limb

C82.05

Follicular lymphoma grade I, lymph nodes of inguinal regional and lower limb

C82.06

Follicular lymphoma grade I, intrapelvic lymph nodes

C82.07

Follicular lymphoma grade I, spleen

C82.08

Follicular lymphoma grade I, lymph nodes of multiple sites

C82.09

Follicular lymphoma grade I, extranodal and solid organ sites

C82.10

Follicular lymphoma grade II, unspecified site

C82.11

Follicular lymphoma grade II, lymph nodes of head, face and neck

C82.12

Follicular lymphoma, grade II, intrathoracic lymph nodes

C82.13

Follicular lymphoma grade II, intra-abdominal lymph nodes

C82.14

Follicular lymphoma grade II, lymph nodes of axilla and upper limb

C82.15

Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb

C82.16

Follicular lymphoma grade II, intrapelvic lymph nodes

C82.17

Follicular lymphoma grade II, spleen

C82.18

Follicular lymphoma grade II, lymph nodes of multiple sites

C82.19

Follicular lymphoma grade II, extranodal and solid organ sites

C82.20

Follicular lymphoma grade III, unspecified, unspecified site

C82.21

Follicular lymphoma grade III, unspecified, lymph nodes of head, face and neck

C82.22

Follicular lymphoma, grade III, unspecified, intrathoracic lymph nodes

C82.23

Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes

C82.24

Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb

C82.25

Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb

C82.26

Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes

C82.27

Follicular lymphoma grade III, unspecified, spleen

C82.28

Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites

C82.29

Follicular lymphoma grade III, unspecified, extranodal and solid organ sites

C82.30

Follicular lymphoma grade IIIa, unspecified site

C82.31

Follicular lymphoma grade IIIa, lymph nodes of head, face and neck

C82.32

Follicular lymphoma, grade IIIa, intrathoracic lymph nodes

C82.33

Follicular lymphoma grade IIIa, intra-abdominal lymph nodes

C82.34

Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb

C82.35

Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb

C82.36

Follicular lymphoma grade IIIa, intrapelvic lymph nodes

C82.37

Follicular lymphoma grade IIIa, spleen

C82.38

Follicular lymphoma grade IIIa, lymph nodes of multiple sites

C82.39

Follicular lymphoma grade IIIa, extranodal and solid organ sites

C82.40

Follicular lymphoma grade IIIb, unspecified site

C82.41

Follicular lymphoma grade IIIb, lymph nodes of head, face and neck

C82.42

Follicular lymphoma, grade IIIb, intrathoracic lymph nodes

C82.43

Follicular lymphoma grade IIIb, intra-abdominal lymph nodes

C82.44

Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb

C82.45

Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb

C82.46

Follicular lymphoma grade IIIb, intrapelvic lymph nodes

C82.47

Follicular lymphoma grade IIIb, spleen

C82.48

Follicular lymphoma grade IIIb, lymph nodes of multiple sites

C82.49

Follicular lymphoma grade IIIb, extranodal and solid organ sites

C82.50

Diffuse follicle center lymphoma, unspecified site

C82.51

Diffuse follicle center lymphoma, lymph nodes of head, face and neck

C82.52

Diffuse follicle center lymphoma, intrathoracic lymph nodes

C82.53

Diffuse follicle center lymphoma, intra-abdominal lymph nodes

C82.54

Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb

C82.55

Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb

C82.56

Diffuse follicle center lymphoma, intrapelvic lymph nodes

C82.57

Diffuse follicle center lymphoma, spleen

C82.58

Diffuse follicle center lymphoma, lymph nodes of multiple sites

C82.59

Diffuse follicle center lymphoma, extranodal and solid organ sites

C82.60

Cutaneous follicle center lymphoma, unspecified site

C82.61

Cutaneous follicle center lymphoma, lymph nodes of head, face and neck

C82.62

Cutaneous follicle center lymphoma, intrathoracic lymph nodes

C82.63

Cutaneous follicle center lymphoma, intra-abdominal lymph nodes

C82.64

Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb

C82.65

Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb

C82.66

Cutaneous follicle center lymphoma, intrapelvic lymph nodes

C82.67

Cutaneous follicle center lymphoma, spleen

C82.68

Cutaneous follicle center lymphoma, lymph nodes of multiple sites

C82.69

Cutaneous follicle center lymphoma, extranodal and solid organ sites

C82.80

Other types of follicular lymphoma, unspecified site

C82.81

Other types of follicular lymphoma, lymph nodes of head, face and neck

C82.82

Other types of follicular lymphoma, intrathoracic lymph nodes

C82.83

Other types of follicular lymphoma, intra-abdominal lymph nodes

C82.84

Other types of follicular lymphoma, lymph nodes of axilla and upper limb

C82.85

Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb

C82.86

Other types of follicular lymphoma, intrapelvic lymph nodes

C82.87

Other types of follicular lymphoma, spleen

C82.88

Other types of follicular lymphoma, lymph nodes of multiple sites

C82.89

Other types of follicular lymphoma, extranodal and solid organ sites

C82.90

Follicular lymphoma, unspecified, unspecified site

C82.91

Follicular lymphoma, unspecified, lymph nodes of head, face and neck

C82.92

Follicular lymphoma, unspecified, intrathoracic lymph nodes

C82.93

Follicular lymphoma, unspecified, intra-abdominal lymph nodes

C82.94

Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb

C82.95

Follicular lymphoma, unspecified lymph nodes of inguinal region and lower limb

C82.96

Follicular lymphoma, unspecified, intrapelvic lymph nodes

C82.97

Follicular lymphoma, unspecified, spleen

C82.98

Follicular lymphoma, unspecified, lymph nodes of multiple sites

C82.99

Follicular lymphoma, unspecified, extranodal and solid organ sites

C83.00

Small cell B-cell lymphoma, unspecified site

C83.01

Small cell B-cell lymphoma, lymph nodes of head, face and neck

C83.02

Small cell B-cell lymphoma, intrathoracic lymph nodes

C83.03

Small cell B-cell lymphoma, intra-abdominal lymph nodes

C83.04

Small cell B-cell lymphoma, lymph nodes of axilla and upper limb

C83.05

Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb

C83.06

Small cell B-cell lymphoma, intrapelvic lymph nodes

C83.07

Small cell B-cell lymphoma, spleen

C83.08

Small cell B-cell lymphoma, lymph nodes of multiple sites

C83.09

Small cell B-cell lymphoma, extranodal and solid organ sites

C83.10

Mantle cell lymphoma, unspecified site

C83.11

Mantle cell lymphoma, lymph nodes of head, face and neck

C83.12

Mantle cell lymphoma, intrathoracic lymph nodes

C83.13

Mantle cell lymphoma, intra-abdominal lymph nodes

C83.14

Mantle cell lymphoma, lymph nodes of axilla and upper limb

C83.15

Mantle cell lymphoma, lymph nodes of inguinal region and lower limb

C83.16

Mantle cell lymphoma, intrapelvic lymph nodes

C83.17

Mantle cell lymphoma, spleen

C83.18

Mantle cell lymphoma, lymph nodes of multiple sites

C83.19

Mantle cell lymphoma, extranodal and solid organ sites

C83.30

Diffuse large B-cell lymphoma unspecified site

C83.31

Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck

C83.32

Diffuse large B-cell lymphoma intrathoracic lymph nodes

C83.33

Diffuse large B-cell lymphoma intra-abdominal lymph nodes

C83.34

Diffuse large B-cell lymphoma lymph nodes of axilla and upper limb

C83.35

Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb

C83.36

Diffuse large B-cell lymphoma intrapelvic lymph nodes

C83.37

Diffuse large B-cell lymphoma, spleen

C83.38

Diffuse large B-cell lymphoma lymph nodes of multiple sites

C83.39

Diffuse large B-cell lymphoma extranodal and solid organ sites

C83.80

Other non-follicular lymphoma, unspecified site

C83.81

Other non-follicular lymphoma, lymph nodes of head, face and neck

C83.82

Other non-follicular lymphoma, intrathoracic lymph nodes

C83.83

Other non-follicular lymphoma, intra-abdominal lymph nodes

C83.84

Other non-follicular lymphoma, lymph nodes of axilla and upper limb

C83.85

Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb

C83.86

Other non-follicular lymphoma, intrapelvic lymph nodes

C83.87

Other non-follicular lymphoma, spleen

C83.88

Other non-follicular lymphoma, lymph nodes of multiple sites

C83.89

Other non-follicular lymphoma, extranodal and solid organ sites

C85.20

Mediastinal (thymic) large B-cell lymphoma, unspecified site

C85.21

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face and neck

C85.22

Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes

C85.23

Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes

C85.24

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb

C85.25

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb

C85.26

Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes

C85.27

Mediastinal (thymic) large B-cell lymphoma, spleen

C85.28

Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites

C85.29

Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites

C85.80

Other specified types of non-Hodgkin lymphoma, unspecified site

C85.81

Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face and neck

C85.82

Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes

C85.83

Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes

C85.84

Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb

C85.85

Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region of lower limb

C85.86

Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes

C85.87

Other specified types of non-Hodgkin lymphoma, spleen

C85.88

Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites

C85.89

Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites

C88.4

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma)

C91.10

Chronic lymphocytic leukemia of B-cell type not having achieved remission

C91.12

Chronic lymphocytic leukemia of B-cell type in relapse

C91.40

Hairy cell leukemia not having achieved remission

C91.42

Hairy cell leukemia, in relapse

D36.0

Benign neoplasm of lymph nodes

D47.Z1

Post-transplant lymphoproliferative disorder (PTLD)

D47.Z2

Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue – Castleman Disease

R59.0

Localized enlarged lymph nodes

R59.1

Generalized enlarged lymph nodes

R59.9

Enlarged lymph nodes, unspecified

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): 6, K

NCD/LCD/LCA Document (s): A52452

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A52452&bc=gAAAAAAAAAAAAA==

Jurisdiction(s): J, M

NCD/LCD/LCA Document (s): A56380

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A56380&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