vp-0208
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Arzerra® (ofatumumab) (Intravenous)

Policy Number: VP-0208

Last Review Date: 04/06/2021

Date of Origin:  08/26/2014

Dates Reviewed:  03/2015, 05/2015, 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, 04/2021

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.

I. Length of Authorization1,5,8,10

Coverage will be provided for 6 months with renewal subject to the following: 

  • CLL/SLL (first-line) may be renewed to allow for a total of 12 cycles
  • CLL/SLL (relapsed or refractory) may not be renewed (unless the provisions for extended treatment have been met)
  • CLL/SLL (extended treatment) may be renewed to provide for a total of 2 years of therapy
  • NHL/FL may be renewed to provide up to a total of 8 doses
  • Waldenström’s Macroglobulinemia/Lymphoplasmacytic lymphoma may be renewed to allow for up to a total of 3 cycles

II. Dosing Limits

  1. Quantity Limit (max daily dose) [NDC Unit]:
  • Arzerra 100 mg/5 mL: 3 vials Day 1
  • Arzerra 1000 mg/50 mL: 2 vials weekly x 7 doses, then 2 vials every 4 weeks, then 1 vial every 8 weeks for up to 24 months
  1. Max Units (per dose and over time) [HCPCS Unit]:

CLL/SLL

First-Line

      • 30 billable units on day 1 and 100 billable units on day 8; then
      • 100 billable units every 28 days for up to 11 doses

Refractory

      • 30 billable units on day 1; then
      • 200 billable units weekly x 7 doses; then
      • 200 billable units every 28 days x 4 doses

Relapsed

      • 30 billable units on day 1 and 100 billable units on day 8; then
    • 100 billable units every 28 days for up to 5 doses

Extended Treatment

      • 30 billable units on day 1 and 100 billable units on day 8; then
      • 100 billable units 7 weeks later and every 8 weeks thereafter

NHL/FL

      • 100 billable units every 7 days x 4 doses
      • 100 billable units every 8 weeks thereafter

Waldenström’s Macroglobulinemia /

Lymphoplasmacytic Lymphoma

      • 30 billable units on day 1; then
      • 200 billable units every 7 days x 4 doses

III. Initial Approval Criteria1-7,10-14

overage is provided in the following conditions:

  • Patient is at least 18 years old; AND

Universal Criteria

  • Patient must be screened for HBV infection (i.e., HBsAg and anti-HBc) prior to initiating therapy; AND
  • Must not be administered concurrently with live vaccines; AND

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

  • Used as first-line therapy in combination with chlorambucil; OR
  • Used as first-line therapy in combination with bendamustine ; AND
  • Patient does not have del(17p)/TP53 mutation; AND
  • Patient is not considered to be frail with significant comorbidities; OR
  • Used for relapsed or refractory disease; AND
      • Used as a single agent; OR
      • Used in combination with fludarabine and cyclophosphamide (FC); OR
  • Used as extended treatment in patients with complete or partial response after 2 or more lines of therapy; AND
    • Used as a single agent

B-Cell Lymphomas ‡

  • Used as a substitute for rituximab or obinutuzumab in patients experiencing rare complications such as mucocutaneous reactions including paraneoplastic pemphigus, Stevens-Johnson syndrome, lichenoid dermatitis, vesiculobullous dermatitis, and toxic epidermal necrolysis; AND
  • Patient has any of the following:
      • Follicular Lymphoma (low grade 1-2)
      • MALT Lymphoma (Gastric or Non-Gastric)
      • Marginal Zone Lymphoma (Splenic or Nodal)
      • Diffuse Large B-Cell Lymphoma (DLBCL)
      • Histologic Transformation of Nodal Marginal Zone Lymphoma to DLBCL
      • Mantle Cell Lymphoma
      • High Grade B-Cell Lymphomas
      • Burkitt Lymphoma
      • AIDS Related B Cell Lymphomas
      • Post-Transplant Lymphoproliferative Disorders
      • Castleman’s Disease

Waldenström’s Macroglobulinemia/Lymphoplasmacytic Lymphoma ‡

  • Used as a single agent OR as part of combination therapy; AND
  • Patient is intolerant to rituximab; AND
    • Patient has previously failed primary therapy; OR
    • Patient has progressive or relapsed disease

FDA Approved Indication(s); Compendia Recommended Indication(s)

IV. Renewal Criteria1-4,7

Authorizations 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
  • Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: Hepatitis B virus reactivation/infection, progressive multifocal leukoencephalopathy, severe infusion reactions, tumor lysis syndrome, cytopenias (neutropenia, anemia, and thrombocytopenia), etc.

V. Dosage/Administration1-5,7,8,10-14

Indication

Dose

CLL/SLL (First-line)

300 mg on Day 1, then 1,000 mg on Day 8, followed by 1,000 mg on Day 1 of subsequent 28-day cycles for a minimum of 3 cycles until best response or a maximum of 12 cycles

CLL/SLL (Refractory)

300 mg on Day 1, followed 1 week later by 2,000 mg given weekly x 7 doses (infusions 2 through 8), followed 4 weeks later by 2,000 mg every 4 weeks for 4 doses (infusions 9 through 12) for a total of 12 doses

CLL/SLL (Relapsed)

300 mg on Day 1, then 1,000 mg on Day 8, followed by 1,000 mg on Day 1 of subsequent 28-day cycles for a maximum of 6 cycles

CLL/SLL (Extended treatment)

300 mg on Day 1, then 1,000 mg on Day 8, followed by 1,000 mg 7 weeks later and every 8 weeks thereafter for up to a maximum of 2 years

NHL

1,000 mg weekly for 4 doses, then 1,000 mg every 8 weeks for 4 doses

Waldenström’s/ Lymphoplasmacytic lymphoma

Cycle 1:

300 mg on day 1, then 1,000 mg weekly for weeks 2 through 4; OR

300 mg on day 1, then 2,000 mg weekly for weeks 2 through 5

Cycle 2-3:

  • Patients with stable disease or a minor response at week 16 of cycle 1 are eligible to receive a re-treatment cycle of 300 mg on day 1, then 2,000 mg for weeks 2 through 5.
  • Patients responding to cycle 1 or the redosing cycle who developed disease progression within 36 months can receive treatment with 300 mg on day 1, then 2,000 mg for weeks 2 through 5.

VI. Billing Code/Availability Information

HCPCS Code:

  • J9302 - injection, ofatumumab, 10 mg; 1 billable unit = 10 mg

NDC:

  • Arzerra 1000 mg/50 mL single-use vial: 00078-0690-xx

http://www.clinicalpharmacology-ip.com/Images/thumb_holder.gif

  • Arzerra 100 mg/5 mL single-use vial: 00078-0669-xx
 

VII. References

  1. Arzerra [package insert]. East Hanover, NJ; Novartis Pharmaceuticals Corporation, August 2016. Accessed February 2021.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) ofatumumab. 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 February 2021.
  3. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. Version 2.2021.  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 February 2021.
  4. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Waldenstrom’s Macroglobulinemia/Lymphoplasmacytic Lymphoma. 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 February 2021.
  1. Furman RR, Eradat H, DiRienzo CG, et al. A phase II trial of ofatumumab in subjects with Waldenstrom's macroglobulinemia. Blood. 2011;118:3701
  2. Wierda WG, Kipps TJ, Mayer J, et al.  Ofatumumab as single-agent CD20 immunotherapy in fludarabine-refractory chronic lymphocytic leukemia. J Clin Oncol 2010;28:1749-1755
  3. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) B-Cell Lymphomas. Version 2.2021.  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 February 2021.
  4. Rosenbaum CA, Jung SH, Pitcher B, et al. Phase 2 multicentre study of single-agent ofatumumab in previously untreated follicular lymphoma: CALGB 50901 (Alliance). Br J Haematol. 2019 Feb 5.
  5. Van Imhoff GW, McMillan A, Matasar MJ et al. Ofatumumab Versus Rituximab Salvage Chemoimmunotherapy in Relapsed or Refractory Diffuse Large B-Cell Lymphoma: The ORCHARRD Study. J Clin Oncol 2017;35 (5):544-551.
  6. Furman RR, Eradat HA, DiRienzo CG, et al. Once-weekly ofatumumab in untreated or relapsed Waldenström's macroglobulinaemia: an open-label, single-arm, phase 2 study. Lancet Haematol. 2017 Jan;4(1):e24-e34. doi: 10.1016/S2352-3026(16)30166-1. Epub 2016 Dec 1.
  7. Hillmen P, Robak T, Janssens A, et al. Chlorambucil plus ofatumumab versus chlorambucil alone in previously untreated patients with chronic lymphocytic leukaemia (COMPLEMENT 1): a randomised, multicentre, open-label phase 3 trial. Lancet. 2015 May 9;385(9980):1873-83. doi: 10.1016/S0140-6736(15)60027-7. Epub 2015 Apr 14.
  8. Robak T, Warzocha K, Govind Babu K, et al. Ofatumumab plus fludarabine and cyclophosphamide in relapsed chronic lymphocytic leukemia: results from the COMPLEMENT 2 trial. Leuk Lymphoma. 2017 May;58(5):1084-1093. doi: 10.1080/10428194.2016.1233536. Epub 2016 Oct 12.
  9. van Oers MH, Kuliczkowski K, Smolej L, et al. Ofatumumab maintenance versus observation in relapsed chronic lymphocytic leukaemia (PROLONG): an open-label, multicentre, randomised phase 3 study. Lancet Oncol. 2015 Oct;16(13):1370-9. doi: 10.1016/S1470-2045(15)00143-6. Epub 2015 Sep 13.
  10. Lemery SJ, Zhang J, Rothmann MD, et al. U.S. Food and Drug Administration Approval: Ofatumumab for the Treatment of Patients with Chronic Lymphocytic Leukemia Refractory to Fludarabine and Alemtuzumab.

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 region 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 site

C82.21

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

C82.22

Follicular lymphoma grade III intrathoracic lymph nodes

C82.23

Follicular lymphoma grade III intra-abdominal lymph nodes

C82.24

Follicular lymphoma grade III lymph nodes of axilla and upper limb

C82.25

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

C82.26

Follicular lymphoma grade III intrapelvic lymph nodes

C82.27

Follicular lymphoma grade III spleen

C82.28

Follicular lymphoma grade III lymph nodes of multiple sites

C82.29

Follicular lymphoma grade III 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 lymph nodes of multiple sites

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 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

C83.70

Burkitt lymphoma, unspecified site

C83.71

Burkitt lymphoma, lymph nodes of head, face, and neck

C83.72

Burkitt lymphoma, intrathoracic lymph nodes

C83.73

Burkitt lymphoma, intra-abdominal lymph nodes

C83.74

Burkitt lymphoma, lymph nodes of axilla and upper limb

C83.75

Burkitt lymphoma, lymph nodes of inguinal region and lower limb

C83.76

Burkitt lymphoma, intrapelvic lymph nodes

C83.77

Burkitt lymphoma, spleen

C83.78

Burkitt lymphoma, lymph nodes of multiple sites

C83.79

Burkitt 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

C83.90

Non-follicular (diffuse) lymphoma, unspecified, unspecified site

C83.91

Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck

C83.92

Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes

C83.93

.93..

Non-follicular (diffuse) lymphoma, unspecified, intra-abdominal lymph nodes

C83.94

Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb

C83.95

Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of inguinal region and lower limb

C83.96

Non-follicular (diffuse) lymphoma, unspecified, intrapelvic lymph nodes

C83.97

Non-follicular (diffuse) lymphoma, unspecified, spleen

C83.98

Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of multiple sites

C83.99

Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites

C85.10

Unspecified B-cell lymphoma, unspecified site

C85.11

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

C85.12

Unspecified B-cell lymphoma, intrathoracic lymph nodes

C85.13

Unspecified B-cell lymphoma, intra-abdominal lymph nodes

C85.14

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

C85.15

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

C85.16

Unspecified B-cell lymphoma, intrapelvic lymph nodes

C85.17

Unspecified B-cell lymphoma, spleen

C85.18

Unspecified B-cell lymphoma, lymph nodes of multiple sites

C85.19

Unspecified B-cell 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 and 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

C88.0

Waldenström macroglobulinemia

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

D47.Z1

Post-transplant lymphoproliferative disorder (PTLD)

D47.Z2

Castleman disease

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 Article (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/LCA/LCD): N/A

                                                                        qA

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