ph-0098
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Denosumab: Prolia®; Xgeva®

Policy Number: PH-0098

Subcutaneous

 

Last Review Date: 04/06/2021

Date of Origin: 11/28/2011

Dates Reviewed: 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 01/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 06/2018, 04/2019, 04/2020, 04/2021

Precertification requirements do not apply for this policy. Pre-payment claim edits are applied to diagnosis criteria within this policy.

 

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.
  1. Length of Authorization

Coverage will be provided for 12 months and may be renewed.

  1. Dosing Limits

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

  • Prolia 60 mg/1 mL single-use prefilled syringe: 1 syringe every 6 months
  • Xgeva 120 mg/1.7 mL single-use vial:
    • Load: 4 vials per 28 days x 1 dose
    • Maintenance: 1 vial monthly

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

Prolia

All indications:

  • 60 billable units every 6 months

Xgeva

Giant Cell Tumor of Bone & Hypercalcemia of Malignancy

  • Loading Dose:
  • 120 billable units on days 1, 8, 15, and 29
  • Maintenance:
  • 120 billable units every 4 weeks

Bone metastases from solid tumors, Multiple Myeloma, & Systemic Mastocytosis:

  • 120 billable units every 4 weeks

  1. Initial Approval Criteria

Prolia

Universal Criteria 1,8

  • Patient must be supplementing with 1,000 mg of calcium and at least 400 IU of vitamin D daily; AND
  • Patient must not have hypocalcemia; AND

Coverage is provided in the following conditions:

  • Patient is at least 18 years of age; AND
  • Patient must be at a high risk for fracture**; AND
  • Pregnancy ruled out prior to starting therapy in women of child-bearing potential; AND

Osteoporosis in Men and Women † 1,17,18,26,27

  • Women only: Patient must be post-menopausal; AND
  • Patient has a documented diagnosis of osteoporosis indicated by one or more of the following:
    • Hip/femur DXA (femoral neck or total hip) or lumbar spine T-score ≤-2.5 and/or forearm DXA 33% (one-third) of the radius; OR
    • T-score ≤-1 or low bone mass and a history of fragility fracture to the hip or spine; OR
    • T-score between -1 and -2.5 with a FRAX 10-year probability for major fracture ≥20% or hip fracture ≥3%; AND
  • Documented treatment failure or ineffective response± to a minimum (12) month trial on previous therapy with bisphosphonates (oral or IV) such as alendronate, risedronate, ibandronate, or zoledronic acid; OR
  • Patient has a documented contraindication* or intolerance to BOTH oral bisphosphonates AND intravenous (IV) bisphosphonates such as alendronate, risedronate, ibandronate, or zoledronic acid

Glucocorticoid-Induced Osteoporosis † 1,19

  • Patient will be initiating or is continuing systemic glucocorticoid therapy at a daily dosage equivalent to ≥ 7.5 mg of prednisone and is expected to remain on glucocorticoid therapy for at least 6 months; AND
    • Documented treatment failure or ineffective response± to a minimum (12) month trial on previous therapy with bisphosphonates (oral or IV) such as alendronate, risedronate, ibandronate, or zoledronic acid; OR
    • Patient has a documented contraindication* or intolerance to BOTH oral bisphosphonates AND intravenous (IV) bisphosphonates such as alendronate, risedronate, ibandronate, or zoledronic acid

Osteoporosis treatment and prevention in prostate cancer patients † 1,3,20

  • Documented Hip DXA (femoral neck or total hip) or lumbar spine T-score ≤-1 (or patient meets the diagnostic criteria for osteoporosis above); AND
  • Patient must be receiving androgen deprivation therapy for non-metastatic prostate cancer

Osteoporosis treatment and prevention in breast cancer patients † 1,3,21

  • Patient must be receiving adjuvant aromatase inhibitor therapy for breast cancer

±Ineffective response is defined as one or more of the following: 8

  • Decrease in T-score in comparison with baseline T-score from DXA scan
  • Patient has a new fracture while on bisphosphonate therapy

**High risk for fractures include, but are not limited to, one or more of the following: 8

  • History of an osteoporotic fracture as an adult
  • Parental history of hip fracture
  • Low BMI
  • Rheumatoid arthritis
  • Alcohol intake (3 or more drinks per day)
  • Current smoking
  • History of oral glucocorticoids ≥5 mg/d of prednisone (or equivalent) for >3 months (ever)

*Examples of contraindications to oral bisphosphonate therapy include the following:

  • Documented inability to sit or stand upright for at least 30 minutes
  • Documented pre-existing gastrointestinal disorder such as inability to swallow, Barrett’s esophagus, esophageal stricture, dysmotility, or achalasia

Xgeva

Universal Criteria 1

  • Administer calcium and vitamin D as necessary to treat or prevent hypocalcemia; AND

Coverage is provided in the following conditions:

Prevention of skeletal-related events in patients with multiple myeloma OR bone metastases from solid tumors † 2,3,14-16,22,25

  • Patient is at least 18 years of age; AND
  • Patient must try and have an inadequate response, contraindication, or intolerance to at least a three (3) month trial of Zoledronic Acid; OR
  • Patient has metastatic breast cancer, metastatic castration-resistant prostate cancer, or metastatic lung cancer (both SCLC and NSCLC)

Giant Cell Tumor of the Bone † Ф 2,3,5,23,24

  • Patient must be an adult or at least 13 years of age and skeletally mature; AND
    • Disease is unresectable or surgical resection is likely to result in severe morbidity; OR
    • Disease is localized, recurrent, or metastatic ; AND
      • Used as a single agent; OR
      • Used in combination with interferon alpha, serial embolization, or radiation therapy

Hypercalcemia of malignancy † Ф 2,3,9

  • Patient is at least 18 years of age; AND
  • Patient must have a diagnosis of cancer (malignancy); AND
    • Patient must have a diagnosis of refractory hypercalcemia of malignancy defined as an albumin-corrected calcium of >12.5 mg/dL (3.1 mmol/L) despite treatment with a minimum seven (7) day trial on previous therapy with intravenous (IV) bisphosphonates such as ibandronate or zoledronic acid; OR
    • Patient has a documented contraindication or intolerance to intravenous (IV) bisphosphonates such as ibandronate or zoledronic acid

Systemic Mastocytosis ‡ 3,28

  • Patient has osteopenia or osteoporosis and coexisting bone pain; AND
  • Used as second line therapy; AND
    • Patient is not responding to bisphosphonate therapy; OR
    • Patient is not a candidate for bisphosphonate therapy due to renal insufficiency

FDA Approved Indication(s); Compendia recommended indication(s); Ф Orphan Drug

  1. Renewal Criteria1,2

Coverage can be renewed based on 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 symptomatic hypocalcemia, osteonecrosis of the jaw, atypical femoral fractures, dermatological adverse reactions, severe infection, severe hypersensitivity/anaphylaxis, musculoskeletal pain, etc.; AND

Prolia 1,3,17-21

  • Disease response as indicated by one or more of the following:
    • Absence of fractures
    • Increase in bone mineral density compared to pretreatment baseline; AND

Osteoporosis in Men and Women ONLY:

    • After 5 years of treatment, patient will have a repeat DXA performed; AND
      • Patients with low-to moderate risk disease will have therapy changed to an oral or IV bisphosphonate unless there is a contraindication or intolerance to both dosage forms

Xgeva 2,3,5,9,14-16,22-24

  • Disease response as indicated by the following:
    • Multiple Myeloma OR Bone metastases from solid tumors: absence/delay in skeletal-related events (e.g., pathologic fracture, radiation therapy to bone, surgery to bone, or spinal cord compression)
    • Giant Cell Tumor of the Bone: stabilization of disease or decrease in size of tumor or spread of tumor
    • Hypercalcemia of Malignancy: corrected serum calcium ≤ 11.5 mg/dL (2.9 mmol/L)
    • Systemic Mastocytosis: improvement or resolution of bone pain as compared to pretreatment baseline
  1. Dosage/Administration 1,2

Prolia

Indication

Dose

All indications

60 mg subcutaneously by a health care provider every 6 months

Xgeva

Indication

Dose

Bone metastases from solid tumors, Multiple Myeloma, & Systemic Mastocytosis

120 mg subcutaneously by a health care provider every 4 weeks

Giant Cell Tumor of Bone

120 mg subcutaneously by a health care provider every 4 weeks with additional 120 mg doses on Days 8 and 15 of the first month of therapy.

Hypercalcemia of Malignancy

120 mg subcutaneously by a health care provider every 4 weeks with additional 120 mg doses on Days 8 and 15 of the first month of therapy.

  1. Billing Code/Availability Information

HCPCS Code:

  • J0897 – Injection, denosumab, 1 mg; 1 mg = 1 billable unit

NDC:

  • Prolia 60 mg/1 mL single-use prefilled syringe: 55513-0710-XX
  • Xgeva 120 mg/1.7 mL single-use vial: 55513-0730-XX
  1. References
  1. Prolia [package insert]. Thousand Oaks, CA; Amgen, Inc.; March 2020. Accessed March 2021.
  2. Xgeva [package insert]. Thousand Oaks, CA; Amgen, Inc.; June 2020. Accessed March 2021.
  3. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Denosumab. National Comprehensive Cancer Network, 2021.  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 2021.
  4. Branstetter DG, Nelson SD, Manivel JC, et al. Denosumab induces tumor reduction and bone formation in patients with giant-cell tumor of bone. Clin Cancer Res. 2012 Aug 15;18(16):4415-24.
  5. Thomas D, Henshaw R, Skubitz K, et al. Denosumab in patients with giant-cell tumor of bone: an open-label, phase 2 study. Lancet Oncol. 2010 Mar;11(3):275-80.
  6. WHO Scientific Group on the Prevention and Management of Osteoporosis. Prevention and management of osteoporosis: report of a WHO scientific group. (WHO technical report series; 921). Geneva, Switzerland: WHO; 2000.
  7. Kanis JA on behalf of the World Health Organization Scientific Group (2007). Assessment of osteoporosis at the primary health care level. Technical Report. World Health Organization Collaborating Center for Metabolic Bone Diseases. University of Sheffield, UK; 2007.
  8. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014.
  9. Hu MI, Glezerman IG, Leboulleux S, et al. Denosumab for treatment of hypercalcemia of malignancy. J Clin Endocrinol Metab. 2014 Sep;99(9):3144-52. doi: 10.1210/jc.2014-1001. Epub 2014 Jun 10.
  10. Camacho PM, Petak SM, Binkley N, et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS - 2016. Endocr Pract. 2016 Sep 2; 22(Suppl 4):1-42.
  11. Gnant M, Pfeiler G, Dubsky PC, et al. Adjuvant denosumab in breast cancer (ABCSG-18): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet. 2015 Aug 1;386(9992):433-43.
  12. Qaseem A, Forciea MA, McLean RM, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update from the American College of Physicians. Ann Intern Med. 2017 May 9. doi: 10.7326/M15-1361.
  13. Jeremiah MP, Unwin BK, Greenawald MH, et al. Diagnosis and Management of Osteoporosis. Am Fam Physician. 2015 Aug 15;92(4):261-8.
  14. Henry DH, Costa L, Goldwasser F, et al. Randomized, Double-Blind Study of Denosumab Versus Zoledronic Acid in the Treatment of Bone Metastases in Patients With Advanced Cancer (Excluding Breast and Prostate Cancer) or Multiple Myeloma. Journal of Clinical Oncology 2011 29:9, 1125-1132. 2011 Mar 20.
  15. Stopeck AT, Lipton A, Body JJ, et al. Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: a randomized, double-blind study. J Clin Oncol. 2010 Dec 10;28(35):5132-9.
  16. Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011 Mar 5;377(9768):813-22.
  17. Cummings SR, San Martin J, McClung MR, et al. Denosumab for Prevention of Fractures in Postmenopausal Women With Osteoporosis. N Engl J Med, 361 (8), 756-65; 2009 Aug 20. PMID: 19671655. DOI: 10.1056/NEJMoa0809493.
  18. Orwoll E, Teglbjaerg CS, Langdahl BL, et al. A Randomized, Placebo-Controlled Study of the Effects of Denosumab for the Treatment of Men With Low Bone Mineral Density. J Clin Endocrinol Metab, 97 (9), 3161-9; Sept 2012. PMID: 22723310. DOI: 10.1210/jc.2012-1569. 
  19. Saag KG, Wagman RB, Geusens P, et al. Denosumab Versus Risedronate in Glucocorticoid-Induced Osteoporosis: A Multicentre, Randomised, Double-Blind, Active-Controlled, Double-Dummy, Non-Inferiority Study. Lancet Diabetes Endocrinol, 6 (6), 445-454; Jun 2018. PMID: 29631782. DOI: 10.1016/S2213-8587(18)30075-5.
  20. Smith MR, Egerdie B, Hernandez Toriz N, et al. Denosumab in Men Receiving Androgen-Deprivation Therapy for Prostate Cancer. N Engl J Med. 2009 Aug 20; 361(8): 745-755.
  21. Ellis GK, Bone HG, Chlebowski R, et al. Randomized Trial of Denosumab in Patients Receiving Adjuvant Aromatase Inhibitors for Nonmetastatic Breast Cancer. J Clin Oncol, 26 (30), 4875-82; 2008 Oct 20. PMID: 18725648. DOI: 10.1200/JCO.2008.16.3832.
  22. Raje N, Terpos E, Willenbacher W, et al. Denosumab Versus Zoledronic Acid in Bone Disease Treatment of Newly Diagnosed Multiple Myeloma: An International, Double-Blind, Double-Dummy, Randomised, Controlled, Phase 3 Study. Lancet Oncol, 19 (3), 370-381; Mar 2018. PMID: 29429912. DOI: 10.1016/S1470-2045(18)30072-X.
  23. Chawla S, Henshaw R, Seeger L, et al. Safety and Efficacy of Denosumab for Adults and Skeletally Mature Adolescents With Giant Cell Tumour of Bone: Interim Analysis of an Open-Label, Parallel-Group, Phase 2 Study. Lancet Oncol, 14 (9), 901-8; Aug 2013. PMID: 23867211. DOI: 10.1016/S1470-2045(13)70277-8.
  24. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Bone Cancer. Version 1.2021.  National Comprehensive Cancer Network, 2021. 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 2021.
  25. Scagliotti GV, Hirsh V, Siena S, et al. Overall Survival Improvement in Patients With Lung Cancer and Bone Metastases Treated With Denosumab Versus Zoledronic Acid: Subgroup Analysis From a Randomized Phase 3 Study. J Thorac Oncol, 7 (12), 1823-1829; Dec 2012. PMID: 23154554. DOI: 10.1097/JTO.0b013e31826aec2b.
  26. Eastell R, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 5, May 2019, Pages 1595–1622, https://doi.org/10.1210/jc.2019-00221. Published: 25 March 2019.
  27. Shoback D, Rosen CJ, Black DM, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab, March 2020, 105(3):1–8. https://academic.oup.com/jcem
  28. Orsolini G, Gavioli I, Tripi G, et al. Denosumab for the Treatment of Mastocytosis-Related Osteoporosis: A Case Series. Calcif Tissue Int. 2017 Jun;100(6):595-598. doi: 10.1007/s00223-017-0241-z.
  29. First Coast Service Options, Inc. Local Coverage Article (LCA): Bisphosphonates (intravenous [IV]) and monoclonal antibodies in the treatment of osteoporosis and their other indications (A55346). Centers for Medicare & Medicaid Services, Inc. Updated on 10/18/2016 with effective date 10/14/2016. Accessed March 2021.
  30. National Government Services, Inc. Local Coverage Article: Billing and Coding: Denosumab (Prolia ™, Xgeva ™) (A52399). Centers for Medicare & Medicaid Services, Inc.  Updated on 09/25/2020 with effective date 10/01/2020. Accessed March 2021.
  31. First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Bisphosphonates (Intravenous [IV]) and Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications (A57603). Centers for Medicare & Medicaid Services, Inc. Updated on 09/25/2020 with effective date 10/01/2020. Accessed March 2021.

Appendix 1 – Covered Diagnosis Codes

Prolia

ICD-10

ICD-10 Description

C50.011- C50.929

Malignant neoplasms of breast

C61

Malignant neoplasm of prostate

M80.00XA- M80.08XS

Age-related osteoporosis with current pathological fracture

M80.80XA- M80.88XS

Other osteoporosis with current pathological fracture

M81.0

Age-related osteoporosis without current pathological fracture

M81.6

Localized osteoporosis [Lequesne]

M81.8

Other osteoporosis without current pathological fracture

M85.80

Other specified disorders of bone density and structure, unspecified site

M85.851

Other specified disorders of bone density and structure, right thigh

M85.852

Other specified disorders of bone density and structure, left thigh

M85.859

Other specified disorders of bone density and structure, unspecified thigh

M85.88

Other specified disorders of bone density and structure, other site

M85.89

Other specified disorders of bone density and structure, multiple sites

T38.0X5A

Adverse effect of glucocorticoids and synthetic analogues, initial encounter

T38.0X5S

Adverse effect of glucocorticoids and synthetic analogues, sequela

Xgeva

ICD-10

ICD-10 Description

C00-C14

Malignant neoplasms of lip, oral cavity and pharynx

C15-C26

Malignant neoplasms of digestive organs

C30-C39

Malignant neoplasms of respiratory and intrathoracic organs

C40-C41

Malignant neoplasms of bone and articular cartilage

C43-C44

Melanoma and other malignant neoplasms of skin

C45-C49

Malignant neoplasms of mesothelial and soft tissue

C50.011- C50.929

Malignant neoplasms of breast

C51-C58

Malignant neoplasms of female genital organs

C60-C63

Malignant neoplasms of male genital organs

C64-C68

Malignant neoplasms of urinary tract

C69-C72

Malignant neoplasms of eye, brain and other parts of central nervous system

C73-C75

Malignant neoplasms of thyroid and other endocrine glands

C7A.00- C7A.8

Malignant neuroendocrine tumors

C7B.00- C7B.8

Secondary neuroendocrine tumors

C76-C80

Malignant neoplasms of ill-defined, other secondary and unspecified sites

C81

Hodgkin lymphoma

C82

Follicular lymphoma

C83

Non-follicular lymphoma

C84

Mature T/NK-cell lymphomas

C85

Other specified and unspecified types of non-Hodgkin lymphoma

C86

Other specified types of T/NK-cell lymphoma

C88

Malignant immunoproliferative diseases and certain other B-cell lymphomas

C90.00

Multiple myeloma not having achieved remission

C90.01

Multiple myeloma in remission

C90.02

Multiple myeloma, in relapse

C90.10

Plasma cell leukemia not having reached remission

C90.11

Plasma cell leukemia in remission

C90.12

Plasma cell leukemia in relapse

C90.20

Extramedullary plasmacytoma not having reached remission

C90.21

Extramedullary plasmacytoma in remission

C90.22

Extramedullary plasmacytoma in relapse

C90.30

Solitary plasmacytoma not having achieved remission

C90.31

Solitary plasmacytoma in remission

C90.32

Solitary plasmacytoma in relapse

C94.30

Mast cell leukemia not having achieved remission

C94.31

Mast cell leukemia, in remission

C94.32

Mast cell leukemia, in relapse

C96

Other and unspecified malignant neoplasms of lymphoid, hematopoietic and related tissue

C96.20

Malignant mast cell neoplasm, unspecified

C96.21

Aggressive systemic mastocytosis

C96.22

Mast cell sarcoma

C96.29

Other malignant mast cell neoplasm

D00-D09

In situ neoplasms

D10-D36

Benign neoplasms, except benign neuroendocrine tumors

D3A.00- D3A.8

Benign neuroendocrine tumors

D37-D44

Neoplasm of uncertain behavior of oral cavity and digestive organs - Neoplasm of uncertain behavior of endocrine glands

D47.02

Systemic mastocytosis

D48

Neoplasm of uncertain behavior of other and unspecified sites

D49.0- D49.9

Neoplasms of unspecified behavior

E83.52

Hypercalcemia

Z85

Personal history of malignant neoplasm

Z85.528

Personal history of other malignant neoplasm of kidney

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 Articles 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/Article):

Prolia and Xgeva

Jurisdiction(s): 6, K

NCD/LCD Document (s): A52399

 https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A52399&bc=gAAAAAAAAAAAAA==

Jurisdiction(s):  N

NCD/LCD Document (s): A55346

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A55346&bc=gAAAAAAAAAAAAA==

Jurisdiction(s): N

NCD/LCD Document (s): A57603

https://www.cms.gov/medicare-coverage-database/search/article-date-search.aspx?DocID=A57603&bc=gAAAAAAAAAAAAA==

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

 

 

 

DENOSUMAB

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