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.

Riabni: For dates of service on or after October 1, 2021, see LCD L35026 and article A56380. For dates of service prior to October 1, 2021, see VP-0109 below.  

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:

Riabni

Rituxan

 Ruxience Truxima

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-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™; Fylnetra® (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-0531 Jelmyto™ (mitomycin) (Intra-pyelocalyceal)
VP-0547 Evomela® (melphalan) (Intravenous)
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-0663 Carvykti™ (ciltacabtagene autoleucel) (Intravenous)