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Opdivo Qvantig™ (nivolumab and hyaluronidase-nvhy)

Policy Number: -90784

(Subcutaneous)

Last Review Date: 10/02/2025

Date of Origin: 02/04/2025

Dates Reviewed: 02/2025, 10/2025

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 ∆ 1,43,47,49,50,52-54,65,68,72,73,79,81,82,89,130,131
  • Initial: Prior authorization validity will be provided initially for 6 months, unless otherwise specified.
    • Use in the treatment of Cutaneous Melanoma:
      • Cutaneous Melanoma neoadjuvant therapy as a single agent: Prior authorization validity may be provided for a maximum of 4 doses.
    • Merkel Cell Carcinoma neoadjuvant therapy: Prior authorization validity may be provided for up to a maximum of 2 doses.
    • Gastric, Esophageal and Esophagogastric/Gastroesophageal Junction Cancer postoperative therapy after surgery: Prior authorization validity may be provided for a maximum of 36 weeks (9 doses).
  • Renewal: Prior authorization validity may be renewed every 6 months thereafter, unless otherwise specified.
    • Non-Small Cell Lung Cancer neoadjuvant treatment followed by optional adjuvant treatment: Prior authorization validity may be provided for a maximum of 4 neoadjuvant doses and 13 adjuvant doses.
    • Prior authorization validity may NOT be renewed for the following indications:
      • Merkel Cell Carcinoma (neoadjuvant therapy)
      • Cutaneous Melanoma (neoadjuvant therapy)
      • Gastric, Esophageal and Esophagogastric/Gastroesophageal Junction Cancer: Post-operative therapy after surgery
    • Prior authorization validity may be renewed up to a maximum of 1 year of therapy* for the following:
      • Cutaneous Melanoma (adjuvant therapy single agent)
      • Esophageal and Esophagogastric/Gastroesophageal Junction Cancer (adjuvant therapy following neoadjuvant chemoradiotherapy)
      • Urothelial Carcinoma (adjuvant therapy)
    • Prior authorization validity may be renewed up to a maximum of 2 years of therapy* for the following:
      • Cervical Cancer
      • Esophageal and Esophagogastric/Gastroesophageal Junction Cancer [induction, first-line, and subsequent therapy (excluding single agent subsequent therapy for squamous cell carcinoma)]
      • Gastric Cancer (first-line therapy or subsequent therapy)
      • Renal Cell Carcinoma (in combination with cabozantinib)
      • Squamous Cell Skin Cancer
      • Vaginal Cancer
      • Vulvar Cancer
      • Urothelial Carcinoma (first line therapy in combination with gemcitabine and cisplatin, followed by single-agent maintenance therapy)

*Note: The maximum number of doses is dependent on the dosing frequency and duration of therapy. Refer to Section V for exact dosage.

Dosing Frequency

Maximum length of therapy

Maximum number of doses

2 weeks

1 year

26 doses

2 years

52 doses

3 weeks

2 years

35 doses

4 weeks

1 year

13 doses

2 years

26 doses
  1. Dosing Limits

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

    • 600 billable units every 4 weeks
  2. Initial Approval Criteria 1

Prior authorization validity is provided in the following conditions:

  • Patient is at least 18 years of age; AND

Universal Criteria

  • Patient has not received previous therapy with a programmed death (PD-1/PD-L1)-directed therapy unless otherwise specified ∆ (Note: Not applicable when used as switch-therapy from intravenous nivolumab); AND
  • Therapy will not be used concomitantly with intravenous nivolumab; AND
  • Therapy will not be used concurrently with intravenous chemotherapy agents (not applicable when used for FDA approved combination therapy indicated with †); AND
  • Intravenous nivolumab must be used in the following:
    • Patients <80 kg; OR
    • Patients requiring 900 mg/15,000 units doseα; OR
    • Patients receiving therapy in combination with ipilimumab; AND

Substitution/Switch-Therapy for Intravenous Nivolumab ‡ 2,4-6,19,20,24,25,31,33,34,36-39,41,42,47-49,61,63-65,72,79-81,83,84,90,94-97,130,131

  • Used as substitution for OR switch-therapy from intravenous nivolumab; AND
    • Patient has previously met criteria for use of intravenous nivolumab [see Opdivo IV policy – Document Number: IC-0226]; AND
      • Patient has been receiving treatment with intravenous nivolumab and has shown a beneficial disease response and absence of unacceptable toxicity while on therapy; OR
    • Patient currently meets criteria for use of intravenous nivolumab [see Opdivo IV policy – Document Number: IC-0226]; AND
  • Patient has any of the following indications for treatment (may not be all inclusive):
    • Ampullary Adenocarcinoma
    • Anal Carcinoma
    • Urothelial Carcinoma (Bladder Cancer)
    • Adult Central Nervous System (CNS) Cancers
    • Cervical Cancer
    • Colorectal Cancer (CRC)
    • Appendiceal Adenocarcinoma – Colon Cancer
    • Gastric Cancer/Esophageal Cancer/Gastroesophageal Junction (GEJ) Cancer
    • Gestational Trophoblastic Neoplasia
    • Squamous Cell Carcinoma of the Head and Neck (SCCHN)
    • Hepatocellular Carcinoma (HCC)
    • Kaposi Sarcoma
    • Renal Cell Carcinoma (RCC)
    • Cutaneous Melanoma
    • Uveal Melanoma
    • Merkel Cell Carcinoma
    • Peritoneal or Pleural Mesothelioma (Note: May also be used for pericardial mesothelioma and tunica vaginalis testis mesothelioma)
    • Non-Small Cell Lung Cancer (NSCLC)
    • Small Bowel Adenocarcinoma
    • Small Cell Lung Cancer (SCLC)
    • Soft Tissue Sarcoma
    • Endometrial carcinoma (Uterine Neoplasms)
    • Vulvar Cancer
    • Thyroid Carcinoma
    • Vaginal Cancer
    • Squamous Cell Skin Cancer

Urothelial Carcinoma (Bladder Cancer) †  1,2,30,51,62,92

  • Used as a single agent; AND
    • Used for locally advanced or metastatic disease that progressed during or following platinum-containing chemotherapy* OR progression with 12 months of neoadjuvant or adjuvant treatment with a platinum-containing regimen; OR
    • Used as adjuvant therapy in patients who are at a high risk for disease recurrence** after undergoing surgical resection; OR
  • Used in combination with cisplatin and gemcitabine; AND
    • Used as first line therapy in patients with unresectable or metastatic disease
  • * Note: 10,51,60,70
  • If patient was progression free for >12 months after platinum therapy, consider re-treatment with platinum-based therapy if the patient is still platinum eligible (see below for cisplatin- or platinum-ineligible comorbidities).
  • Cisplatin-ineligible comorbidities may include the following: CrCl < 60 mL/min, ECOG PS ≥ 2 or KPS ≤ 70%, hearing loss of ≥ 25 decibels (dB) at two contiguous frequencies, grade ≥ 2 peripheral neuropathy, or NYHA Heart Failure class ≥ 3. Carboplatin may be substituted for cisplatin in the metastatic setting for cisplatin-ineligible patients such as those with a GFR less than 60 mL/min.
  • Platinum-ineligible comorbidities may include the following: CrCl < 30 mL/min, ECOG PS ≥ 3, grade ≥ 2 peripheral neuropathy, or NYHA Heart Failure class > 3, etc.
  • ** Note: 1,62
  • High risk for disease recurrence is defined as:
  • ypT2-ypT4a or ypN+ for patients who received neoadjuvant platinum-based therapy (excluding urothelial carcinoma of the prostate with stromal invasion); OR
  • pT3-pT4a or pN+ for patients who did not receive neoadjuvant platinum-based therapy

Colorectal Cancer (CRC) † 1,2,31,32

  • Patient has microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR) disease as determined by an FDA-approved or CLIA-compliant testv; AND
  • Used as a single agent; AND
  • Used as subsequent therapy for metastatic disease; AND
  • Patient has disease progression following treatment with a fluoropyrimidine, oxaliplatin and irinotecan regimen

Gastric Cancer/Esophageal Cancer/Gastroesophageal Junction (GEJ) Cancer † 1,2,44,52,56,69

  • Used as a single agent; AND
      • Used as adjuvant treatment of completely resected esophageal or GEJ cancer with residual pathologic disease in patients who have received neoadjuvant chemoradiotherapy (CRT).; OR
      • Used as subsequent therapy after prior fluoropyrimidine- and platinum-based chemotherapy; AND
        • Used for unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma (ESCC); OR
  • Used in combination with fluoropyrimidine- and platinum-containing chemotherapy; AND
      • Used as first-line therapy; AND
      • Tumor expresses PD-L1 (CPS ≥1) as determined by an FDA-approved or CLIA compliant testv; AND
        • Used in patients with unresectable, advanced or metastatic esophageal squamous cell carcinoma (ESCC); OR
        • Used for advanced or metastatic gastric, GEJ, or esophageal adenocarcinomas

Squamous Cell Carcinoma of the Head and Neck (SCCHN) † 1,2,29,78

  • Used as single-agent therapy; AND
  • Patient has metastatic disease with disease progression on or after platinum-based therapy; AND
  • Patient does not have disease of the nasopharynx

Hepatocellular Carcinoma (HCC) † 1,2,21,86,87

  • Used as a single agent; AND
  • Patient was previously treated with sorafenib and following treatment with intravenous nivolumab/ipilimumab

Renal Cell Carcinoma (RCC) † 1,2,25,26

  • Used as a single agent; AND
    • Used as first line therapy in patients with intermediate or poor risk advanced disease following treatment with intravenous nivolumab/ ipilimumab; OR
    • Used as subsequent therapy after prior anti-angiogenic therapy; OR
  • Used in combination with cabozantinib (Cabometyx only); AND
    • Used as first-line therapy for advanced disease

Cutaneous Melanoma † 1,2,15-18,82,93

  • Used as single agent therapy; AND
    • Used as first-line therapy for unresectable or metastatic disease; OR
    • Used as subsequent therapy for unresectable or metastatic disease following treatment with intravenous nivolumab/ipilimumab; OR
  • Used as adjuvant treatment and patient has stage IIB, stage IIC, stage III or metastatic disease and has undergone complete resection

Non-Small Cell Lung Cancer (NSCLC) † 1,2,22,23,43,45,46

  • Used as single-agent therapy; AND
    • Used for metastatic disease; AND
    • Used as subsequent therapy on or after platinum-based chemotherapy (Note: Patients with EGFR or ALK genomic tumor aberrations should have disease progression on targeted therapies prior to receiving subcutaneous nivolumab); OR
  • Used in combination with platinum-doublet chemotherapy; AND
    • Used as neoadjuvant therapy in patients who have resectable (tumors ≥ 4 cm or node positive) disease; OR
  • Used as neoadjuvant therapy in resectable disease with the option of continuing to single-agent subcutaneous nivolumab therapy as adjuvant treatment after surgery

vIf confirmed using an FDA approved assay – http://www.fda.gov/companiondiagnostics  

† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug

  1. Renewal Criteria ∆ 1,2,4-6,15-42,43,47,49,50,52-54,68,72,73,79,81,82,89

Prior authorization validity 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
  • Duration of authorization has not been exceeded (refer to Section I); 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: immune-mediated adverse reactions (e.g., pneumonitis, hepatitis, colitis, endocrinopathies, nephritis/renal dysfunction, rash/dermatitis [including Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS), and toxic epidermal necrolysis (TEN)], myocarditis, pericarditis, vasculitis, solid organ transplant rejection, etc.), severe infusion-related reactions, complications of allogeneic hematopoietic stem cell transplantation (HSCT), etc.

Δ Notes:

  • Patients responding to therapy who relapse ≥ 6 months after discontinuation due to duration are eligible to re-initiate PD-directed therapy.
  • Patients previously presenting with aggressive disease who are exhibiting stable disease on treatment as their best response (or if therapy improved performance status) may be eligible for continued therapy without interruption or discontinuation.
  • Patients who complete adjuvant therapy and progress ≥ 6 months after discontinuation are eligible to re-initiate PD-directed therapy for metastatic disease.
  • Patients whose tumors, upon re-biopsy, demonstrate a change in actionable mutation (e.g., MSS initial biopsy; MSI-H subsequent biopsy) may be eligible to re-initiate PD-directed therapy and will be evaluated on a case-by-case basis.
  • Patients diagnosed with Renal Cell Carcinoma with clear cell histology who have received previous immuno-oncology therapy may be eligible for treatment with nivolumab as subsequent therapy and will be evaluated on a case-by-case basis.

  1. Dosage/Administration ∆ 1,14,19,20,27,28,31-42,48-50,52-54,55,58,59,61,65,67,68,71-87,89,91,93,96,98-119,122-125,128-131  

Indication

Dose

Renal Cell Carcinoma
  • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity; OR
  • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks administered in combination with cabozantinib up to a maximum of 2 years of therapy

Cutaneous Melanoma

Unresectable or metastatic disease:

  • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity

Adjuvant treatment:

  • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks until disease recurrence or unacceptable toxicity for up to 1 year

Neoadjuvant treatment:

  • 600 mg/10,000 units every 14 days for 4 doses

Uveal Melanoma
  • 600 mg/10,000 units every 2 weeks, until disease progression or unacceptable toxicity

Merkel Cell Carcinoma

Neoadjuvant treatment:

  • 600 mg/10,000 units every 2 weeks (days 1 and 15) for a total of 2 doses

All other settings:

  • 600 mg/10,000 units every 2 weeks, until disease progression or unacceptable toxicity

NSCLC

Neoadjuvant treatment: †

  • α900 mg/15,000 units with platinum-doublet chemotherapy on the same day every 3 weeks for up to 4 cycles

Adjuvant treatment:

    • 1,200 mg/20,000 units every 4 weeks after surgery for up to 13 cycles (up to one year) or until disease progression, recurrence, or unacceptable toxicity

Single agent:

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity

Urothelial Carcinoma

Adjuvant treatment:

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease recurrence or unacceptable toxicity for up to 1 year

Disease progression or second-line treatment:

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity

First-line therapy: †

    •  α900 mg/15,000 units every 3 weeks with cisplatin and gemcitabine on the same day for up to 6 cycles, followed by:
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years

Esophageal and Esophagogastric/ Gastroesophageal Junction Cancer

First-line therapy (MSI-H/dMMR adenocarcinoma and squamous cell carcinoma):

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years

First line therapy (PD-L1 positive disease): †

  • 600 mg/10,000 units every 2 weeks in combination with fluoropyrimidine- and platinum-containing chemotherapy every 2 weeks, until disease progression or unacceptable toxicity for up to 2 years
  •  α900 mg/15,000 units every 3 weeks with fluoropyrimidine- and platinum containing chemotherapy every 3 weeks, until disease progression or unacceptable toxicity for up to 2 years

Subsequent therapy (MSI-H/dMMR adenocarcinoma and squamous cell carcinoma):

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years

Subsequent therapy (squamous cell carcinoma):

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity

Post-operative therapy (MSI-H/dMMR adenocarcinoma following preoperative therapy with intravenous nivolumab/ipilimumab):

    • 1,200 mg/20,000 units every 4 weeks for 36 weeks (9 doses)

Adjuvant therapy following neoadjuvant chemoradiotherapy:

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 1 year

Induction therapy for relieving dysphagia (MSI-H/dMMR squamous cell carcinoma):

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years

Gastric Cancer

First-line therapy:

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years; OR
    • 600 mg/10,000 units every 2 weeks in combination with fluoropyrimidine- and platinum-containing chemotherapy every 2 weeks, until disease progression or unacceptable toxicity for up to 2 years †.

Subsequent therapy:

    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years

Post-operative therapy (following preoperative therapy with intravenous nivolumab/ipilimumab):

    • 1,200 mg/20,000 units every 4 weeks, every 4 weeks for 36 weeks (9 doses)

Soft Tissue Sarcoma, Kaposi Sarcoma
    • 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity

Squamous Cell Skin cancer
    • 600 mg/10,000 units every 2 weeks until disease progression or unacceptable toxicity for up to 2 years

Vulvar Cancer, Vaginal Cancer, & Cervical Cancer
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity for up to 2 years

All other indications
    • 600 mg/10,000 units every 2 weeks or 1,200 mg/20,000 units every 4 weeks, until disease progression or unacceptable toxicity

Note:

  • αThe 900 mg/15,000 units dosing is listed in the prescribing information; however, the IV formulation of nivolumab must be used instead to prevent wastage.
  • Opdivo Qvantig (nivolumab and hyaluronidase-nvhy) has different dosage and administration instructions than intravenous nivolumab products.
  • Opdivo Qvantig is for subcutaneous use only in the abdomen or thigh.
  • Opdivo Qvantig is to be administered by a healthcare professional only.
  • Opdivo Qvantig is for subcutaneous use only administered over 3-5 minutes.
  1. Billing Code/Availability Information

HCPCS Code:

  • J9289 – Injection, nivolumab, 2 mg and hyaluronidase-nvhy; 1 billable unit = 2 mg

NDC(s):

  • Opdivo Qvantig single-dose vial providing 600 mg nivolumab and 10,000 units hyaluronidase per 5 mL (120 mg/ 2,000 units per mL): 00003-6120-xx
  1. References
  1. Opdivo Qvantig [package insert]. Princeton, NJ; Bristol-Myers Squibb, Inc; June 2025. Accessed September 2025.
  1. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) nivolumab and hyaluronidase-nvhy. National Comprehensive Cancer Network, 2025. 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 September 2025.
  2. Scherpereel A, Mazieres J, Greillier L, et al. Second- or third-line nivolumab (Nivo) versus nivo plus ipilimumab (Ipi) in malignant pleural mesothelioma (MPM) patients: Results of the IFCT-1501 MAPS2 randomized phase II trial. [Abstract]. J Clin Oncol 2017;35: Abstract LBA 8507.
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  4. Tawbi HA-H, Forsyth PAJ, Algazi AP, et al. Efficacy and safety of nivolumab (NIVO) plus ipilimumab (IPI) in patients with melanoma (MEL) metastatic to the brain: Results of the phase II study CheckMate 204. J Clin Oncol 2017;35(15_suppl):abstr 9507.
  5. Morris VK, Salem ME, Nimeiri H, et al.  Nivolumab for previously treated unresectable metastatic anal cancer (NCI9673): a multicentre, single-arm, phase 2 study. Lancet Oncol. 2017 Apr;18(4):446-453. Doi: 10.1016/S1470-2045(17)30104-3. Epub 2017 Feb 18.
  6. Zhao X, Ivaturi V, Gopalakrishnan M, et al. Abstract CT 101: A model-based exposure-response (E-R) assessment of a nivolumab (NIVO) 4-weekly (Q4W) dosing schedule across multiple tumor types. Cancer Res July 1 2017 (77) (13 Supplement) CT101; DOI: 10.1158/1538-7445.AM2017-CT101.
  7. Zhao X, Suryawanshi M, Hruska M, et al. Assessment of nivolumab benefit-risk profile of a 240 mg flat dose relative to a 3 mg/kg dosing regimen in patients with advanced tumors. Ann Oncol2017; 28:2002-2008.
  8. Feng Y, Xiaoning W, Bajaj G, et al. Nivolumab exposure-response analyses of efficacy and safety in previously treated squamous or nonsquamous non-small cell lung cancer. ClinCa Res 2017;23(18): 5394-5405.
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  17. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Nivolumab: Endometrial Carcinoma Chemotherapy Order Template, UTE34. National Comprehensive Cancer Network, 2024. 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 September 2024.
  18. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Nivolumab: Cervical Cancer Chemotherapy Order Template, CRV35. National Comprehensive Cancer Network, 2024. 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 September 2024.
  19. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Nivolumab: Vulvar Cancer Chemotherapy Order Template, VUL17. National Comprehensive Cancer Network, 2024. 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 September 2024.
  20. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Nivolumab: Vaginal Cancer Chemotherapy Order Template, VAG34. National Comprehensive Cancer Network, 2024. 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 September 2024.
  21. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Brentuximab vedotin + Nivolumab: Hodgkin Lymphoma Chemotherapy Order Template, HDL53. National Comprehensive Cancer Network, 2024. 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 September 2024.
  22. Herrera AF, LeBlanc ML, Castellino SM, et al. SWOG S1826, a randomized study of nivolumab(N)-AVD versus brentuximab vedotin(BV)-AVD in advanced stage (AS) classic Hodgkin lymphoma (HL). Journal of Clinical Oncology 2023;41:LBA4-LBA4.
  23. Bröckelmann PJ, Buhen I, Meissner J et al. Nivolumab and Doxorubicin, Vinblastine, and Dacarbazine in Early-Stage Unfavorable Hodgkin Lymphoma: Final Analysis of the Randomized German Hodgkin Study Group Phase II NIVAHL Trial. J Clin Oncol. 2023 Feb 20;41(6):1193-1199. doi: 10.1200/JCO.22.02355. Epub 2022 Dec 12. PMID: 36508302.
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  25. Cascone T, Awad MM, Spicer JD, et al. Perioperative Nivolumab in Resectable Lung Cancer. N Engl J Med. 2024 May 16;390(19):1756-1769. doi: 10.1056/NEJMoa2311926. PMID: 38749033.
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  28. Referenced with permission from the NCCN Clinical Practice Guidelines (NCCN Guidelines®) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Version 3.2025. National Comprehensive Cancer Network, 2025. 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 Guidelines, go online to NCCN.org. Accessed September 2025.
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  34. Patel SP, Othus M, Chae YK, et al. Phase II basket trial of dual anti-CTLA-4 and anti-PD-1 blockade in rare tumors (DART) SWOG S1609: Adrenocortical carcinoma cohort. J Immunother Cancer 2024;12:e009074.
  35. Munhoz RR, Nader-Marta G, de Camargo VP, et al. A phase 2 study of first-line nivolumab in patients with locally advanced or metastatic cutaneous squamous-cell carcinoma. Cancer. 2022;128(24):4223-4231. doi:10.1002/cncr.34463
  36. Lang R, Welponer T, Richtig E, et al. Nivolumab for locally advanced and metastatic cutaneous squamous cell carcinoma (NIVOSQUACS study)-Phase II data covering impact of concomitant haematological malignancies. J Eur Acad Dermatol Venereol. 2023;37(9):1799-1810. doi:10.1111/jdv.19218
  37. Harker-Murray P, Mauz-Korholz C, Leblanc T, et al. Nivolumab and brentuximab vedotin with or without bendamustine for R/R Hodgkin lymphoma in children, adolescents, and young adults. Blood 2023;141:2075-2084.
  38. Greve P, Beishuizen A, Hagleitner M, et al. Nivolumab plus brentuximab vedotin +/- bendamustine combination therapy: A safe and effective treatment in pediatric recurrent and refractory classical Hodgkin lymphoma. Front Immunol 2023;14:1229558.

Appendix A – Non-Quantitative Treatment Limitations (NQTL) Factor Checklist

Non-quantitative treatment limitations (NQTLs) refer to the methods, guidelines, standards of evidence, or other conditions that can restrict how long or to what extent benefits are provided under a health plan. These may include things like utilization review or prior authorization. The utilization management NQTL applies comparably, and not more stringently, to mental health/substance use disorder (MH/SUD) Medical Benefit Prescription Drugs and medical/surgical (M/S) Medical Benefit Prescription Drugs. The table below lists the factors that were considered in designing and applying prior authorization to this drug/drug group, and a summary of the conclusions that Prime’s assessment led to for each.

Factor

Conclusion

Indication

Yes: Consider for PA

Safety and efficacy

No: PA not a priority

Potential for misuse/abuse

No: PA not a priority

Cost of drug

Yes: Consider for PA

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

C00.0

Malignant neoplasm of external upper lip

C00.1

Malignant neoplasm of external lower lip

C00.2

Malignant neoplasm of external lip, unspecified

C00.3

Malignant neoplasm of upper lip, inner aspect

C00.4

Malignant neoplasm of lower lip, inner aspect

C00.5

Malignant neoplasm of lip, unspecified, inner aspect

C00.6

Malignant neoplasm of commissure of lip, unspecified

C00.8

Malignant neoplasm of overlapping sites of lip

C00.9

Malignant neoplasm of lip, unspecified

C01

Malignant neoplasm of base of tongue

C02.0

Malignant neoplasm of dorsal surface of tongue

C02.1

Malignant neoplasm of border of tongue

C02.2

Malignant neoplasm of ventral surface of tongue

C02.3

Malignant neoplasm of anterior two-thirds of tongue, part unspecified

C02.4

Malignant neoplasm of lingual tonsil

C02.8

Malignant neoplasm of overlapping sites of tongue

C02.9

Malignant neoplasm of tongue, unspecified

C03.0

Malignant neoplasm of upper gum

C03.1

Malignant neoplasm of lower gum

C03.9

Malignant neoplasm of gum, unspecified

C04.0

Malignant neoplasm of anterior floor of mouth

C04.1

Malignant neoplasm of lateral floor of mouth

C04.8

Malignant neoplasm of overlapping sites of floor of mouth

C04.9

Malignant neoplasm of floor of mouth, unspecified

C05.0

Malignant neoplasm of hard palate

C05.1

Malignant neoplasm of soft palate

C05.8

Malignant neoplasm of overlapping sites of palate

C05.9

Malignant neoplasm of palate, unspecified

C06.0

Malignant neoplasm of cheek mucosa

C06.2

Malignant neoplasm of retromolar area

C06.80

Malignant neoplasm of overlapping sites of unspecified parts of mouth

C06.89

Malignant neoplasm of overlapping sites of other parts of mouth

C06.9

Malignant neoplasm of mouth, unspecified

C09.0

Malignant neoplasm of tonsillar fossa

C09.1

Malignant neoplasm of tonsillar pillar (anterior) (posterior)

C09.8

Malignant neoplasm of overlapping sites of tonsil

C09.9

Malignant neoplasm of tonsil, unspecified

C10.0

Malignant neoplasm of vallecula

C10.1

Malignant neoplasm of anterior surface of epiglottis

C10.2

Malignant neoplasm of lateral wall of oropharynx

C10.3

Malignant neoplasm of posterior wall of oropharynx

C10.4

Malignant neoplasm of branchial cleft

C10.8

Malignant neoplasm of overlapping sites of oropharynx

C10.9

Malignant neoplasm of oropharynx, unspecified

C11.0

Malignant neoplasm of superior wall of nasopharynx

C11.1

Malignant neoplasm of posterior wall of nasopharynx

C11.2

Malignant neoplasm of lateral wall of nasopharynx

C11.3

Malignant neoplasm of anterior wall of nasopharynx

C11.8

Malignant neoplasm of overlapping sites of nasopharynx

C11.9

Malignant neoplasm of nasopharynx, unspecified

C12

Malignant neoplasm of pyriform sinus

C13.0

Malignant neoplasm of postcricoid region

C13.1

Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect

C13.2

Malignant neoplasm of posterior wall of hypopharynx

C13.8

Malignant neoplasm of overlapping sites of hypopharynx

C13.9

Malignant neoplasm of hypopharynx, unspecified

C14.0

Malignant neoplasm of pharynx, unspecified

C14.2

Malignant neoplasm of Waldeyer’s ring

C14.8

Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C15.3

Malignant neoplasm of upper third of esophagus

C15.4

Malignant neoplasm of middle third of esophagus

C15.5

Malignant neoplasm of lower third of esophagus

C15.8

Malignant neoplasm of overlapping sites of esophagus

C15.9

Malignant neoplasm of esophagus, unspecified

C16.0

Malignant neoplasm of cardia

C16.1

Malignant neoplasm of fundus of stomach

C16.2

Malignant neoplasm of body of stomach

C16.3

Malignant neoplasm of pyloric antrum

C16.4

Malignant neoplasm of pylorus

C16.5

Malignant neoplasm of lesser curvature of stomach, unspecified

C16.6

Malignant neoplasm of greater curvature of stomach, unspecified

C16.8

Malignant neoplasm of overlapping sites of stomach

C16.9

Malignant neoplasm of stomach, unspecified

C17.0

Malignant neoplasm of duodenum

C17.1

Malignant neoplasm of jejunum

C17.2

Malignant neoplasm of ileum

C17.3

Meckel’s diverticulum, malignant

C17.8

Malignant neoplasm of overlapping sites of small intestine

C17.9

Malignant neoplasm of small intestine, unspecified

C18.0

Malignant neoplasm of cecum

C18.1

Malignant neoplasm of appendix

C18.2

Malignant neoplasm of ascending colon

C18.3

Malignant neoplasm of hepatic flexure

C18.4

Malignant neoplasm of transverse colon

C18.5

Malignant neoplasm of splenic flexure

C18.6

Malignant neoplasm of descending colon

C18.7

Malignant neoplasm of sigmoid colon

C18.8

Malignant neoplasm of overlapping sites of colon

C18.9

Malignant neoplasm of colon, unspecified

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.0

Malignant neoplasm of anus, unspecified

C21.1

Malignant neoplasm of anal canal

C21.2

Malignant neoplasm of cloacogenic zone

C21.8

Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C22.0

Liver cell carcinoma

C22.8

Malignant neoplasm of liver, primary, unspecified as to type

C22.9

Malignant neoplasm of liver, not specified as primary or secondary

C24.1

Malignant neoplasm of ampulla of Vater

C30.0

Malignant neoplasm of nasal cavity

C31.0

Malignant neoplasm of maxillary sinus

C31.1

Malignant neoplasm of ethmoidal sinus

C32.0

Malignant neoplasm of glottis

C32.1

Malignant neoplasm of supraglottis

C32.2

Malignant neoplasm of subglottis

C32.3

Malignant neoplasm of laryngeal cartilage

C32.8

Malignant neoplasm of overlapping sites of larynx

C32.9

Malignant neoplasm of larynx, unspecified

C33

Malignant neoplasm of trachea

C34.00

Malignant neoplasm of unspecified main bronchus

C34.01

Malignant neoplasm of right main bronchus

C34.02

Malignant neoplasm of left main bronchus

C34.10

Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11

Malignant neoplasm of upper lobe, right bronchus or lung

C34.12

Malignant neoplasm of upper lobe, left bronchus or lung

C34.2

Malignant neoplasm of middle lobe, bronchus or lung

C34.30

Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31

Malignant neoplasm of lower lobe, right bronchus or lung

C34.32

Malignant neoplasm of lower lobe, left bronchus or lung

C34.80

Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81

Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82

Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90

Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91

Malignant neoplasm of unspecified part of right bronchus or lung

C34.92

Malignant neoplasm of unspecified part of left bronchus or lung

C43.0

Malignant melanoma of lip

C43.111

Malignant melanoma of right upper eyelid, including canthus

C43.112

Malignant melanoma of right lower eyelid, including canthus

C43.121

Malignant melanoma of left upper eyelid, including canthus

C43.122

Malignant melanoma of left lower eyelid, including canthus

C43.20

Malignant melanoma of unspecified ear and external auricular canal

C43.21

Malignant melanoma of right ear and external auricular canal

C43.22

Malignant melanoma of left ear and external auricular canal

C43.30

Malignant melanoma of unspecified part of face

C43.31

Malignant melanoma of nose

C43.39

 Malignant melanoma of other parts of face

C43.4

Malignant melanoma of scalp and neck

C43.51

Malignant melanoma of anal skin

C43.52

Malignant melanoma of skin of breast

C43.59

Malignant melanoma of other part of trunk

C43.60

Malignant melanoma of unspecified upper limb, including shoulder

C43.61

Malignant melanoma of right upper limb, including shoulder

C43.62

Malignant melanoma of left upper limb, including shoulder

C43.70

Malignant melanoma of unspecified lower limb, including hip

C43.71

Malignant melanoma of right lower limb, including hip

C43.72

Malignant melanoma of left lower limb, including hip

C43.8

Malignant melanoma of overlapping sites of skin

C43.9

Malignant melanoma of skin, unspecified

C44.00

Unspecified malignant neoplasm of skin of lip

C44.02

Squamous cell carcinoma of skin of lip

C44.09

Other specified malignant neoplasm of skin of lip

C44.121

Squamous cell carcinoma of skin of unspecified eyelid, including canthus

C44.1221

Squamous cell carcinoma of skin of right upper eyelid, including canthus

C44.1222

Squamous cell carcinoma of skin of right lower eyelid, including canthus

C44.1291

Squamous cell of carcinoma of skin of left upper eyelid, including canthus

C44.1292

Squamous cell carcinoma of skin of left lower eyelid, including canthus

C44.221

Squamous cell carcinoma of skin of unspecified ear and external auricular canal

C44.222

Squamous cell carcinoma of skin of right ear and external auricular canal

C44.229

Squamous cell carcinoma of skin of left ear and external auricular canal

C44.320

Squamous cell carcinoma of skin of unspecified parts of face

C44.321

Squamous cell carcinoma of skin of nose

C44.329

Squamous cell carcinoma of skin of other parts of face

C44.42

Squamous cell carcinoma of skin of scalp and neck

C44.520

Squamous cell carcinoma of anal skin

C44.521

Squamous cell carcinoma of skin of breast

C44.529

Squamous cell carcinoma of skin of other part of trunk

C44.621

Squamous cell carcinoma of skin of unspecified upper limb, including shoulder

C44.622

Squamous cell carcinoma of skin of right upper limb, including shoulder

C44.629

Squamous cell carcinoma of skin of left upper limb, including shoulder

C44.721

Squamous cell carcinoma of skin of unspecified lower limb, including hip

C44.722

Squamous cell carcinoma of skin of right lower limb, including hip

C44.729

Squamous cell carcinoma of skin of left lower limb, including hip

C44.82

Squamous cell carcinoma of overlapping sites of skin

C44.92

Squamous cell carcinoma of skin, unspecified

C45.0

Mesothelioma of pleura

C45.1

Mesothelioma of peritoneum

C45.2

Mesothelioma of pericardium

C45.7

Mesothelioma of other sites

C45.9

Mesothelioma, unspecified

C46.0

Kaposi’s sarcoma of skin

C46.1

Kaposi’s sarcoma of soft tissue

C46.2

Kaposi’s sarcoma of palate

C46.3

Kaposi’s sarcoma of lymph nodes

C46.4

Kaposi’s sarcoma of gastrointestinal sites

C46.50

Kaposi’s sarcoma of unspecified lung

C46.51

Kaposi’s sarcoma of right lung

C46.52

Kaposi’s sarcoma of left lung

C46.7

Kaposi’s sarcoma of other sites

C46.9

Kaposi’s sarcoma, unspecified

C47.0

Malignant neoplasm of peripheral nerves of head, face and neck

C47.10

Malignant neoplasm of peripheral nerves of unspecified upper limb, including shoulder

C47.11

Malignant neoplasm of peripheral nerves of right upper limb, including shoulder

C47.12

Malignant neoplasm of peripheral nerves of left upper limb, including shoulder

C47.20

Malignant neoplasm of peripheral nerves of unspecified lower limb, including hip

C47.21

Malignant neoplasm of peripheral nerves of right lower limb, including hip

C47.22

Malignant neoplasm of peripheral nerves of left lower limb, including hip

C47.3

Malignant neoplasm of peripheral nerves of thorax

C47.4

Malignant neoplasm of peripheral nerves of abdomen

C47.5

Malignant neoplasm of peripheral nerves of pelvis

C47.6

Malignant neoplasm of peripheral nerves of trunk, unspecified

C47.8

Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system

C47.9

Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified

C48.0

Malignant neoplasm of retroperitoneum

C48.1

Malignant neoplasm of specified parts of peritoneum

C48.2

Malignant neoplasm of peritoneum, unspecified

C48.8

Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum

C49.0

Malignant neoplasm of connective and soft tissue of head, face and neck

C49.10

Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder

C49.11

Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder

C49.12

Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder

C49.20

Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip

C49.21

Malignant neoplasm of connective and soft tissue of right lower limb, including hip

C49.22

Malignant neoplasm of connective and soft tissue of left lower limb, including hip

C49.3

Malignant neoplasm of connective and soft tissue of thorax

C49.4

Malignant neoplasm of connective and soft tissue of abdomen

C49.5

Malignant neoplasm of connective and soft tissue of pelvis

C49.6

Malignant neoplasm of connective and soft tissue of trunk, unspecified

C49.8

Malignant neoplasm of overlapping sites of connective and soft tissue

C49.9

Malignant neoplasm of connective and soft tissue, unspecified

C4A.0

Merkel cell carcinoma of lip

C4A.10

Merkel cell carcinoma of eyelid, including canthus

C4A.111

Merkel cell carcinoma of right upper eyelid, including canthus

C4A.112

Merkel cell carcinoma of right lower eyelid, including canthus

C4A.121

Merkel cell carcinoma of left upper eyelid, including canthus

C4A.122

Merkel cell carcinoma of left lower eyelid, including canthus

C4A.20

Merkel cell carcinoma of unspecified ear and external auricular canal

C4A.21

Merkel cell carcinoma of right ear and external auricular canal

C4A.22

Merkel cell carcinoma of left ear and external auricular canal

C4A.30

Merkel cell carcinoma of unspecified part of face

C4A.31

Merkel cell carcinoma of nose

C4A.39

Merkel cell carcinoma of other parts of face

C4A.4

Merkel cell carcinoma of scalp and neck

C4A.51

Merkel cell carcinoma of anal skin

C4A.52

Merkel cell carcinoma of skin of breast

C4A.59

Merkel cell carcinoma of other part of trunk

C4A.60

Merkel cell carcinoma of unspecified upper limb, including shoulder

C4A.61

Merkel cell carcinoma of right upper limb, including shoulder

C4A.62

Merkel cell carcinoma of left upper limb, including shoulder

C4A.70

Merkel cell carcinoma of unspecified lower limb, including hip

C4A.71

Merkel cell carcinoma of right lower limb, including hip

C4A.72

Merkel cell carcinoma of left lower limb, including hip

C4A.8

Merkel cell carcinoma of overlapping sites

C4A.9

Merkel cell carcinoma, unspecified

C51.0

Malignant neoplasm of labium majus

C51.1

Malignant neoplasm of labium minus

C51.2

Malignant neoplasm of clitoris

C51.8

Malignant neoplasm of overlapping sites of vulva

C51.9

Malignant neoplasm of vulva, unspecified

C52

Malignant neoplasm of vagina

C53.0

Malignant neoplasm of endocervix

C53.1

Malignant neoplasm of exocervix

C53.8

Malignant neoplasm of overlapping sites of cervix uteri

C53.9

Malignant neoplasm of cervix uteri, unspecified

C54.0

Malignant neoplasm of isthmus uteri

C54.1

Malignant neoplasm of endometrium

C54.2

Malignant neoplasm of myometrium

C54.3

Malignant neoplasm of fundus uteri

C54.8

Malignant neoplasm of overlapping sites of corpus uteri

C54.9

Malignant neoplasm of corpus uteri, unspecified

C55

Malignant neoplasm of uterus, part unspecified

C58

Malignant neoplasm of placenta

C61

Malignant neoplasm of prostate

C64.1

Malignant neoplasm of right kidney, except renal pelvis

C64.2

Malignant neoplasm of left kidney, except renal pelvis

C64.9

Malignant neoplasm of unspecified kidney, except renal pelvis

C65.1

Malignant neoplasm of right renal pelvis

C65.2

Malignant neoplasm of left renal pelvis

C65.9

Malignant neoplasm of unspecified renal pelvis

C66.1

Malignant neoplasm of right ureter

C66.2

Malignant neoplasm of left ureter

C66.9

Malignant neoplasm of unspecified ureter

C67.0

Malignant neoplasm of trigone of bladder

C67.1

Malignant neoplasm of dome of bladder

C67.2

Malignant neoplasm of lateral wall of bladder

C67.3

Malignant neoplasm of anterior wall of bladder

C67.4

Malignant neoplasm of posterior wall of bladder

C67.5

Malignant neoplasm of bladder neck

C67.6

Malignant neoplasm of ureteric orifice

C67.7

Malignant neoplasm of urachus

C67.8

Malignant neoplasm of overlapping sites of bladder

C67.9

Malignant neoplasm of bladder, unspecified

C68.0

Malignant neoplasm of urethra

C69.30

Malignant neoplasm of unspecified choroid

C69.31

Malignant neoplasm of right choroid

C69.32

Malignant neoplasm of left choroid

C69.40

Malignant neoplasm of unspecified ciliary body

C69.41

Malignant neoplasm of right ciliary body

C69.42

Malignant neoplasm of left ciliary body

C69.60

Malignant neoplasm of unspecified orbit

C69.61

Malignant neoplasm of right orbit

C69.62

Malignant neoplasm of left orbit

C73

Malignant neoplasm of thyroid gland

C76.0

Malignant neoplasm of head, face and neck

C77.0

Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck

C78.00

Secondary malignant neoplasm of unspecified lung

C78.01

Secondary malignant neoplasm of right lung

C78.02

Secondary malignant neoplasm of left lung

C78.6

Secondary malignant neoplasm of retroperitoneum and peritoneum

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

C79.31

Secondary malignant neoplasm of brain

C79.89

Secondary malignant neoplasm of other specified sites

C7A.1

Malignant poorly differentiated neuroendocrine tumors

C7B.1

Secondary Merkel cell carcinoma

D09.0

Carcinoma in situ of bladder

D37.01

Neoplasm of uncertain behavior of lip

D37.02

Neoplasm of uncertain behavior of tongue

D37.05

Neoplasm of uncertain behavior of pharynx

D37.09

Neoplasm of uncertain behavior of other specified sites of the oral cavity

D37.1

Neoplasm of uncertain behavior of stomach

D37.8

Neoplasm of uncertain behavior of other specified digestive organs

D37.9

Neoplasm of uncertain behavior of digestive organ, unspecified

D38.0

Neoplasm of uncertain behavior of larynx

D38.5

Neoplasm of uncertain behavior of other respiratory organs

D38.6

Neoplasm of uncertain behavior of respiratory organ, unspecified

D39.2

Neoplasm of uncertain behavior of placenta

O01.9

Hydatidiform mole, unspecified

Z85.00

Personal history of malignant neoplasm of unspecified digestive organ

Z85.01

Personal history of malignant neoplasm of esophagus

Z85.028

Personal history of other malignant neoplasm of stomach

Z85.068

Personal history of other malignant neoplasm of small intestine

Z85.09

Personal history of malignant neoplasm of other digestive organs

Z85.118

Personal history of other malignant neoplasm of bronchus and lung

Z85.12

Personal history of malignant neoplasm of trachea

Z85.42

Personal history of malignant neoplasm of other parts of uterus

Z85.51

Personal history of malignant neoplasm of bladder

Z85.59

Personal history of malignant neoplasm of other urinary tract organ

Z85.820

Personal history of malignant melanoma of skin 

Z85.821

Personal history of Merkel cell carcinoma

Z85.831

Personal history of malignant neoplasm of soft tissue

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

The preceding information is intended for non-Medicare coverage determinations. 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 Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A

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

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA

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