Current Provider-Administered Oncology Drug Policies

Kanjinti: See VP-0057 below.

Nyvepria: For dates of service on or after January 1, 2021, see LCD L37176/article A56748. For dates of service prior to January 1, 2021, see VP-0234 below.

Provenge: See NCD 110.22 for Autologous Cellular Immunotherapy Treatment.

Rituximab: For Riabni, see VP-0109 below. For Rituxan, Truxima and Ruxience, see LCD L35026 and article A56380

Trazimera: See VP-0057 below.

Ziextenzo: See VP-0234 below.


For billing and coding for chemotherapy, refer to Palmetto article A56141 for the following drugs:

Adcetris

Aliqopa

Arzerra

Bavencio

Beleodaq

Belrapzo

Bendeka

Besponsa

Blincyto

bortezomib, not otherwise specified

Campath

Cyramza

Darzalex

Doxil

Imfinzi

Empliciti

Erwinaze

Gazyva

Halaven

Herceptin

Herceptin Hylecta

Herzuma

Imfinzi

Istodax

Ixempra

Kadcyla

Keytruda

Kyprolis

Lartruvo

Lutathera

Mylotarg Ogivri Onivyde

Ontruzant

Opdivo

Perjeta

Portrazza

Poteligeo

Tecentriq
Torisel Treanda Velcade
Vumon

Vyxeos

Yervoy

Yondelis

Zaltrap

 

For chimeric antigen receptor (CAR) T-cell therapy for cancers, refer to NCD 110.24 for the following,

Abecma

Breyanzi

Kymriah

Tecartus Yescarta  

For erythropoiesis stimulating agents (ESAs) in cancer and related neoplastic conditions, refer to NCD 110.21.

darbepoetin alfa

epoetin alfa

For billing and coding for Rituximab, refer to LCD L35026/article A56380 for the following drugs:

Rituxan

Truxima

Ruxience

For white cell colony stimulating factors, refer to LCD L37176/article A56748 for the following drugs:

Fulphila Granix Leukine
Neulasta Neupogen Nivestym
Nyvepria Udenyca Zarxio

Policy # Policy Title Print View
VP-0007 Pemetrexed: Alimta®; Pemfexy™ (Intravenous)
VP-0008 Aloxi® (palonosetron) (Intravenous)
VP-0014 Bevacizumab: Avastin®; Mvasi™; Zirabev™ (Intravenous)
VP-0036 Emend® (fosaprepitant dimeglumine) (Intravenous)
VP-0038 Erbitux® (cetuximab) (Intravenous)
VP-0043 Faslodex® (fulvestrant) (Intramuscular)
VP-0057 Trastuzumab: Herceptin®; Ogivri™; Kanjinti™; Trazimera™; Herzuma™; Ontruzant™ (Intravenous)
VP-0089 Nplate™ (romiplostim) (Subcutaneous)
VP-0109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ (Intravenous)
VP-0136 Vectibix® (panitumumab) (Intravenous)
VP-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca™; Ziextenzo™; Nyvepria™ (Subcutaneous)
VP-0336 Cinvanti™ (aprepitant) (Intravenous)
VP-0363 Akynzeo® (fosnetupitant/palonosetron) (Intravenous)
VP-0398 Libtayo® (cemiplimab-rwlc) (Intravenous)
VP-0482 Polivy™ (polatuzumab vedotin-piiq) (Intravenous)
VP-0503 Reblozyl® (luspatercept-aamt) (Subcutaneous)
VP-0521 Padcev™ (enfortumab vedotin-ejfv) (Intravenous)
VP-0522 Enhertu® (fam-trastuzumab deruxtecan-nxki) (Intravenous)
VP-0528 Sarclisa® (isatuximab-irfc) (Intravenous)
VP-0531 Jelmyto™ (mitomycin) (Intra-pyelocalyceal)
VP-0532 Trodelvy™ (sacituzumab govitecan-hziy) (Intravenous)
VP-0535 Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) (Subcutaneous)
VP-0547 Evomela® (melphalan) (Intravenous)
VP-0550 Zepzelca™ (lurbinectedin) (Intravenous)
VP-0553 Phesgo™ (pertuzumab, trastuzumab and hyaluronidase-zzxf) (Subcutaneous)
VP-0559 Monjuvi™ (tafasitamab-cxix) (Intravenous)
VP-0561 Blenrep® (belantamab mafodotin-blmf) (Intravenous)
VP-0581 Danyelza® (naxitamab-gqgk) (Intravenous)
VP-0583 Margenza™ (margetuximab-cmkb) (Intravenous)
VP-0595 Pepaxto® (melphalan flufenamide) (Intravenous)