vp-0130 - vp-0130 - Medical Policies
Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ (Intravenous)
Policy Number: VP-0130
Last Review Date: 02/02/2023
Date of Origin: 01/01/12
Dates Reviewed: 12/2011, 02/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 12/2019, 03/2020, 06/2020, 09/2020, 03/2021, 03/2022, 06/2022, 01/2023, 02/2023
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 Authorization 1-6,9,14,18
- Waldenström’s Macroglobulinemia (WM)/Lymphoplasmacytic Lymphoma (LPL):
- Coverage will be provided for six months and may NOT be renewed, unless otherwise specified.
- May be renewed for an additional six months for relapsed disease if previously used as primary therapy.
- Coverage will be provided for six months and may NOT be renewed, unless otherwise specified.
- Non-Hodgkin Lymphoma (NHL), Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL), Hodgkin Lymphoma, Systemic Light Chain Amyloidosis:
- Coverage will be provided for six months and may NOT be renewed.
- Multiple Myeloma:
- Coverage will be provided for eight months and may NOT be renewed.
- HSCT Conditioning:
- Coverage will be provided for one time only and may NOT be renewed.
II. Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
- Treanda 100 mg single-dose vial: 6 vials every 21 days
- Treanda 25 mg single-dose vial: 3 vials every 21 days
- Bendeka 100 mg/4 mL multi-dose vial: 6 vials every 21 days
- Belrapzo 100 mg/4 mL RTD multi-dose vial: 6 vials every 21 days
- Vivimusta 100 mg/4 mL multi-dose vial: 6 vials every 21 days
- Max Units (per dose and over time) [HCPCS Unit]:
NHL:
- 600 billable units every 21 days
WM/LPL:
- 450 billable units every 28 days
Hodgkin Lymphoma:
- 600 billable units every 28 days
CLL/SLL, Systemic Light Chain Amyloidosis & Multiple Myeloma:
- 500 billable units every 28 days
HSCT Conditioning:
- 1000 billable units one time only
III. Initial Approval Criteria 1-4
Coverage is provided in the following conditions:
- Patient is at least 18 years of age, unless otherwise specified; AND
- Patient must not have received bendamustine in a previous line of therapy, unless otherwise specified; AND
Non-Hodgkin Lymphoma (NHL) † Ф 1-5,16
- Coverage is provided for B-Cell Lymphomas when:
- Used as subsequent therapy †; AND
-
- In combination with rituximab for:
- AIDS-Related Diffuse Large B-cell Lymphoma (DLBCL), primary effusion lymphoma, or HHV8-positive DLBCL, not otherwise specified (NOS)
- Follicular Lymphoma (grade 1-2)
- Gastric MALT Lymphoma
- In combination with rituximab for:
-
-
-
-
-
- High-grade B-cell Lymphomas
-
-
-
-
-
-
-
- Mantle Cell Lymphoma (may also be used as a component of RBAC500 [rituximab, bendamustine, and cytarabine])
-
-
-
-
-
-
-
- Nodal Marginal Zone Lymphoma
- Non-Gastric MALT Lymphoma (Noncutaneous)
- Monomorphic Post-Transplant Lymphoproliferative Disorder (B-cell type)
- Splenic Marginal Zone Lymphoma; OR
-
- Used as a single agent for:
-
- AIDS-Related B-cell Lymphomas (i.e., DLBCL, primary effusion lymphoma, HHV8-positive DLBCL NOS, or plasmablastic lymphoma in non-candidates for transplant)
- Follicular Lymphoma (grade 1-2)
-
-
-
-
-
-
-
- High-grade B-cell Lymphomas
- Monomorphic Post-Transplant Lymphoproliferative Disorder (B-cell type); OR
-
- In combination with obinutuzumab for:
-
- Follicular Lymphoma (grade 1-2)
-
-
-
-
-
-
-
- Gastric MALT Lymphoma
- Nodal Marginal Zone Lymphoma
- Non-Gastric MALT Lymphoma (Noncutaneous)
-
-
-
-
-
-
-
- Splenic Marginal Zone Lymphoma; OR
-
- In combination with polatuzumab (with or without rituximab) for:
-
- AIDS-Related DLBCL, primary effusion lymphoma, or HHV8-positive DLBCL, NOS
- AIDS-Related plasmablastic lymphoma in non-candidates for transplant (excluding use with rituximab)
- DLBCL
- Follicular Lymphoma (grade 1-2)
- Histologic transformation of indolent lymphomas to DLBCL
- High-grade B-cell Lymphomas
- Monomorphic Post-Transplant Lymphoproliferative Disorder (B-cell type); OR
-
-
-
- Used as first line therapy ‡; AND
-
- In combination with rituximab for:
- Follicular Lymphoma (grade 1-2)
- In combination with rituximab for:
-
-
-
-
-
- Gastric MALT Lymphoma
- Mantle Cell Lymphoma (may also be used as a component of RBAC500 [rituximab, bendamustine, and cytarabine])
- Nodal Marginal Zone Lymphoma
- Non-Gastric MALT Lymphoma (Noncutaneous)
- Splenic Marginal Zone Lymphoma; OR
- In combination with obinutuzumab for:
- Follicular Lymphoma
- Nodal Marginal Zone Lymphoma
-
-
-
- Used as CAR T-cell bridging therapy after leukapheresis ‡; AND
-
- In combination with polatuzumab (with or without rituximab) for:
- AIDS-Related DLBCL, primary effusion lymphoma, or HHV8-positive DLBCL, NOS
- AIDS-Related plasmablastic lymphoma in non-candidates for transplant (excluding use with rituximab)
- High-grade B-cell Lymphomas
- DLBCL
- Monomorphic Post-Transplant Lymphoproliferative Disorder (B-cell type)
- In combination with polatuzumab (with or without rituximab) for:
-
- Coverage is provided for the following T-Cell Lymphomas ‡
- Adult T-Cell Leukemia/Lymphoma
- Used as subsequent therapy for non-responders to first-line therapy as a single agent for acute or lymphoma subtypes
- Breast Implant-Associated Anaplastic Large Cell Lymphoma (ALCL)
- Used as subsequent therapy as a single agent for relapsed or refractory disease
- Hepatosplenic T-Cell Lymphoma
- Used as subsequent therapy as a single agent for refractory disease after two first-line therapy regimens
- Peripheral T-Cell Lymphoma (includes peripheral T-cell not otherwise specified, enteropathy-associated T-cell, monomorphic epitheliotropic intestinal T-cell, angioimmunoblastic T-cell, nodal peripheral T-cell with TFH phenotype, follicular T-cell, or anaplastic large cell lymphomas)
- Used as a single agent; AND
- Used as subsequent therapy for relapsed or refractory disease; OR
- Used as initial palliative intent therapy in transplant ineligible patients
- Adult T-Cell Leukemia/Lymphoma
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) † Ф 1-5,17
- Used as first-line therapy; AND
- Used as a single agent †; OR
- Used in combination with rituximab or obinutuzumab for disease without del(17p)/TP53 mutations (excluding use in frail patients [i.e., not able to tolerate purine analogs]); OR
- Used as subsequent therapy, after prior Bruton Tyrosine Kinase inhibitor- and venetoclax-based regimens; AND
- Used in combination with rituximab for disease without del(17p)/TP53 mutations in patients <65 years of age without significant comorbidities
Waldenström’s Macroglobulinemia/Lymphoplasmacytic Lymphoma (WM/LPL) ‡ 5
- Used as a single agent or in combination with rituximab; AND
- Used as primary therapy; OR
- Used for relapse, if previously used as primary therapy that was well tolerated and elicited a prolonged response; OR
- Used as alternative therapy for previously treated disease that does not respond to primary therapy; OR
- Used for progressive or relapsed disease
Adult Hodgkin Lymphoma ‡ 5,6
- Patient has classic Hodgkin Lymphoma (cHL); AND
- Used as second-line or subsequent therapy for relapsed or refractory disease; AND
- Used in combination with gemcitabine and vinorelbine; OR
- Used in combination with brentuximab vedotin; OR
- Used as subsequent fourth-line therapy for relapsed or refractory disease; AND
- Used as a single agent; OR
- Used as second-line or subsequent therapy for relapsed or refractory disease; AND
-
-
- Used in combination with carboplatin and etoposide; OR
- Used as palliative therapy as a single agent for relapsed or refractory disease in patients >60 years of age; OR
-
- Patient has Nodular Lymphocyte-Predominant Hodgkin Lymphoma (NLPHL); AND
- Used as subsequent therapy for progressive, relapsed, or refractory disease; AND
- Used in combination with rituximab
Pediatric Hodgkin Lymphoma ‡ 5,6
- Patient age is 18 years and under*; AND
- Used as re-induction therapy or subsequent therapy for relapsed or refractory disease; AND
- Used in combination with brentuximab vedotin
* Pediatric Hodgkin Lymphoma may be applicable to adolescent and young adult (AYA) patients up to the age of 39 years.
Multiple Myeloma ‡ 5
- Used for relapsed or progressive (after at least 3 prior therapies) disease; AND
- Used as a single agent; OR
- Used in combination with dexamethasone and either lenalidomide or bortezomib
Systemic Light Chain Amyloidosis ‡ 5,18
- Patient has relapsed or refractory disease; AND
- Used in combination with dexamethasone
Hematopoietic Cell Transplantation‡ 5,19
- Used as conditioning for autologous transplant; AND
- Used in combination with etoposide, cytarabine and melphalan (BEAM); AND
- Patient has Non-Hodgkin Lymphoma without CNS disease or Hodgkin Lymphoma
† FDA-labeled indication(s); ‡ Compendia recommended indication(s); Ф Orphan Drug
IV. Renewal Criteria 1-5
Coverage may be renewed based upon the following criteria:
- Patient continues to meet the 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: severe myelosuppression, infections, progressive multifocal leukoencephalopathy (PML), anaphylaxis, severe infusion reactions, tumor lysis syndrome (TLS), fatal and serious skin reactions, fatal and serious hepatotoxicity, secondary malignancies, extravasation injury, etc.; AND
Waldenström’s Macroglobulinemia/Lymphoplasmacytic Lymphoma (if bendamustine was previously used as primary therapy)
- Refer to Section III for criteria (see WM/LPL)
All Other Indications
- Coverage may not be renewed.
V. Dosage/Administration 1-6,9,14,18
Indication |
Dose |
Non-Hodgkin Lymphoma |
Up to 120 mg/m² intravenously on days 1 and 2 of a 21-day cycle, up to 8 cycles |
CLL/SLL & Systemic Light Chain Amyloidosis |
Up to 100 mg/m² intravenously on days 1 and 2 of a 28-day cycle, up to 6 cycles |
Waldenström’s Macroglobulinemia/ Lymphoplasmacytic Lymphoma |
Up to 90 mg/m2 intravenously on days 1 and 2 of a 28-day cycle, up to 6 cycles *May be repeated for relapsed disease if primary therapy was well tolerated and elicited a prolonged response. |
Hodgkin Lymphoma |
Up to 120 mg/m² intravenously on days 1 and 2 of a 28-day cycle, up to 6 cycles |
Multiple Myeloma |
Up to 100 mg/m² intravenously on days 1 and 2 of a 28-day cycle, up to 8 cycles |
Conditioning for HSCT |
Up to 200 mg/m² intravenously on days –7 and –6 leading up to transplant. |
VI. Billing Code/Availability Information
HCPCS Code:
- J9033 – Injection, bendamustine hcl (treanda), 1 mg; 1 billable unit = 1 mg
- J9034 – Injection, bendamustine hcl (bendeka), 1 mg; 1 billable unit = 1 mg
- J9036 – Injection, bendamustine hcl, (belrapzo/bendamustine), 1 mg; 1 billable unit = 1 mg
- J9999 – Not otherwise classified, antineoplastic drugs (Applicable to other unclassified 505(b)(2) NDA not listed, inclusive of Vivimusta, ONLY) Ψ
- C9399 – Unclassified drugs or biologicals (Applicable to other unclassified 505(b)(2) NDA not listed, inclusive of Vivimusta, ONLY) Ψ
NDC(s):
- Treanda 100 mg lyophilized powder in a single-dose vial for reconstitution: 63459-0391-xx
- Treanda 25 mg lyophilized powder in a single-dose vial for reconstitution: 63459-0390-xx
- Treanda 45 mg/0.5 mL solution in a single dose vial: 63459-0395-xx * §
- Treanda 180 mg/2 mL solution in a single dose vial: 63459-0396-xx * §
- Bendeka 100 mg/4 mL solution in a multi-dose vial: 63459-0348-xx § Ψ
- Belrapzo 100 mg/4 mL ready-to-dilute multi-dose vial: 42367-0521-xx Ψ
- Vivimusta 100 mg/4 mL solution in a multi-dose vial: 71225-0120-xx Ψ
Ψ Designated products approved by the FDA as a 505(b)(2) NDA of the innovator product. These products are not rated as therapeutically equivalent to their reference listed drug in the Food and Drug Administration’s (FDA) Orange Book and are therefore considered single source products based on the statutory definition of “single source drug” in section 1847A(c)(6) of the Act. For a complete list of all approved 505(b)(2) NDA products please reference the latest edition of the Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations | Orange Book | FDA |
- References
- Treanda [package insert]. North Wales, PA; Cephalon, Inc; October 2022. Accessed December 2022.
- Bendeka [package insert]. North Wales, PA; Teva Pharmaceuticals USA, Inc.; October 2021. Accessed December 2022.
- Belrapzo [package insert]. Woodcliff, NJ; Eagle Pharmaceuticals, Inc; June 2022. Accessed December 2022.
- Vivimusta [package insert]. Princeton, NJ; Slayback Pharma, Inc; December 2022. Accessed December 2022.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for bendamustine. National Comprehensive Cancer Network, 2022. 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 December 2022.
- Moskowitz AJ, Hamlin PA Jr, Perales MA, et al. Phase II study of bendamustine in relapsed and refractory Hodgkin lymphoma. J Clin Oncol. 2013;31(4):456-460.
- Kahl BS, Bartlett NL, Leonard JP, et al. Bendamustine is effective therapy in patients with rituximab-refractory, indolent B-cell non-Hodgkin lymphoma: results from a Multicenter Study. Cancer. 2010;116(1):106-114. doi:10.1002/cncr.24714.
- Knauf WU, Lissitchkov T, Aldaoud A, et al. Bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukaemia: updated results of a randomized phase III trial. Br J Haematol. 2012;159(1):67-77. doi:10.1111/bjh.12000.
- Rummel MJ, Niederle N, Maschmeyer G, et al. Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial [published correction appears in Lancet. 2013 Apr 6;381(9873):1184]. Lancet. 2013;381(9873):1203-1210. doi:10.1016/S0140-6736(12)61763-2.
- O'Connor OA, Lue JK, Sawas A, et al. Brentuximab vedotin plus bendamustine in relapsed or refractory Hodgkin's lymphoma: an international, multicentre, single-arm, phase 1-2 trial. Lancet Oncol 2018; 19:257-266.
- Santoro A, Mazza R, Pulsoni A, et al. Bendamustine in Combination With Gemcitabine and Vinorelbine Is an Effective Regimen As Induction Chemotherapy Before Autologous Stem-Cell Transplantation for Relapsed or Refractory Hodgkin Lymphoma: Final Results of a Multicenter Phase II Study. J Clin Oncol 2016; 34:3293.
- Budde LE, Wu D, Martin DB, et al. Bendamustine with rituximab, etoposide and carboplatin (T(R)EC) in relapsed or refractory aggressive lymphoma: a prospective multicentre phase 1/2 clinical trial. Br J Haematol. 2018;183(4):601-607. doi:10.1111/bjh.15585.
- Ludwig H, Kasparu H, Leitgeb C, et al. Bendamustine-bortezomib-dexamethasone is an active and well-tolerated regimen in patients with relapsed or refractory multiple myeloma. Blood. 2014;123(7):985-991. doi:10.1182/blood-2013-08-521468.
- Lentzsch S, O'Sullivan A, Kennedy RC, et al. Combination of bendamustine, lenalidomide, and dexamethasone (BLD) in patients with relapsed or refractory multiple myeloma is feasible and highly effective: results of phase 1/2 open-label, dose escalation study. Blood. 2012;119(20):4608-4613. doi:10.1182/blood-2011-12-395715.
- Knop S, Straka C, Haen M, Schwedes R, Hebart H, Einsele H. The efficacy and toxicity of bendamustine in recurrent multiple myeloma after high-dose chemotherapy. Haematologica. 2005;90(9):1287-1288.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for B-Cell Lymphomas 5.2022. National Comprehensive Cancer Network, 2022. 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 December 2022.
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma 1.2023. National Comprehensive Cancer Network, 2022. 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 December 2022.
- Lentzsch S, Lagos G, Comenzo R, et.al. Bendamustine With Dexamethasone in Relapsed/Refractory Systemic Light-Chain Amyloidosis: Results of a Phase II Study. J Clin Oncol. 2020 May 1;38(13):1455-1462. doi: 10.1200/JCO.19.01721. Epub 2020 Feb 21.
- Frankiewicz A, Saduś-Wojciechowska M, Najda J, et al. Comparable safety profile of BeEAM (bendamustine, etoposide, cytarabine, melphalan) and BEAM (carmustine, etoposide, cytarabine, melphalan) as conditioning before autologous haematopoietic cell transplantation. Contemp Oncol (Pozn) 2018;22:113-117
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
C81.00 |
Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site |
C81.01 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.02 |
Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes |
C81.03 |
Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.04 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.05 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.06 |
Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes |
C81.07 |
Nodular lymphocyte predominant Hodgkin lymphoma, spleen |
C81.08 |
Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites |
C81.09 |
Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites |
C81.10 |
Nodular sclerosis Hodgkin lymphoma, unspecified site |
C81.11 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.12 |
Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes |
C81.13 |
Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.14 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.15 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.16 |
Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes |
C81.17 |
Nodular sclerosis Hodgkin lymphoma, spleen |
C81.18 |
Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites |
C81.19 |
Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites |
C81.20 |
Mixed cellularity Hodgkin lymphoma, unspecified site |
C81.21 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.22 |
Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes |
C81.23 |
Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.24 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.25 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.26 |
Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes |
C81.27 |
Mixed cellularity Hodgkin lymphoma, spleen |
C81.28 |
Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites |
C81.29 |
Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites |
C81.30 |
Lymphocyte depleted Hodgkin lymphoma, unspecified site |
C81.31 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.32 |
Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes |
C81.33 |
Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.34 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.35 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.36 |
Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes |
C81.37 |
Lymphocyte depleted Hodgkin lymphoma, spleen |
C81.38 |
Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites |
C81.39 |
Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites |
C81.40 |
Lymphocyte-rich Hodgkin lymphoma, unspecified site |
C81.41 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck |
C81.42 |
Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes |
C81.43 |
Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes |
C81.44 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb |
C81.45 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
C81.46 |
Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes |
C81.47 |
Lymphocyte-rich Hodgkin lymphoma, spleen |
C81.48 |
Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites |
C81.49 |
Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites |
C81.70 |
Other Hodgkin lymphoma unspecified site |
C81.71 |
Other Hodgkin lymphoma lymph nodes of head, face, and neck |
C81.72 |
Other Hodgkin lymphoma intrathoracic lymph nodes |
C81.73 |
Other Hodgkin lymphoma intra-abdominal lymph nodes |
C81.74 |
Other Hodgkin lymphoma lymph nodes of axilla and upper limb |
C81.75 |
Other Hodgkin lymphoma lymph nodes of inguinal region and lower limb |
C81.76 |
Other Hodgkin lymphoma intrapelvic lymph nodes |
C81.77 |
Other Hodgkin lymphoma spleen |
C81.78 |
Other Hodgkin lymphoma lymph nodes of multiple sites |
C81.79 |
Other Hodgkin lymphoma extranodal and solid organ sites |
C81.90 |
Hodgkin lymphoma, unspecified, unspecified site |
C81.91 |
Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck |
C81.92 |
Hodgkin lymphoma, unspecified, intrathoracic lymph nodes |
C81.93 |
Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes |
C81.94 |
Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb |
C81.95 |
Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
C81.96 |
Hodgkin lymphoma, unspecified, intrapelvic lymph nodes |
C81.97 |
Hodgkin lymphoma, unspecified, spleen |
C81.98 |
Hodgkin lymphoma, unspecified, lymph nodes of multiple sites |
C81.99 |
Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
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 regional 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, unspecified site |
C82.21 |
Follicular lymphoma grade III, unspecified, lymph nodes of head, face and neck |
C82.22 |
Follicular lymphoma, grade III, unspecified, intrathoracic lymph nodes |
C82.23 |
Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes |
C82.24 |
Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb |
C82.25 |
Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb |
C82.26 |
Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes |
C82.27 |
Follicular lymphoma grade III, unspecified, spleen |
C82.28 |
Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites |
C82.29 |
Follicular lymphoma grade III, unspecified, 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 |
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, 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 |
C83.37 |
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 |
C83.80 |
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 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 |
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 |
C84.40 |
Peripheral T-cell lymphoma, not classified, unspecified site |
C84.41 |
Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck |
C84.42 |
Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes |
C84.43 |
Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes |
C84.44 |
Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb |
C84.45 |
Peripheral T-cell lymphoma, not classified, lymph nodes of inguinal region and lower limb |
C84.46 |
Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes |
C84.47 |
Peripheral T-cell lymphoma, not classified, spleen |
C84.48 |
Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites |
C84.49 |
Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites |
C84.60 |
Anaplastic large cell lymphoma, ALK-positive, unspecified site |
C84.61 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck |
C84.62 |
Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes |
C84.63 |
Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes |
C84.64 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb |
C84.65 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb |
C84.66 |
Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes |
C84.67 |
Anaplastic large cell lymphoma, ALK-positive, spleen |
C84.68 |
Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites |
C84.69 |
Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites |
C84.7A |
Anaplastic large cell lymphoma, ALK-negative, breast |
C84.70 |
Anaplastic large cell lymphoma, ALK-negative, unspecified site |
C84.71 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck |
C84.72 |
Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes |
C84.73 |
Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes |
C84.74 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb |
C84.75 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb |
C84.76 |
Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes |
C84.77 |
Anaplastic large cell lymphoma, ALK-negative, spleen |
C84.78 |
Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites |
C84.79 |
Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites |
C84.90 |
Mature T/NK-cell lymphomas, unspecified, unspecified site |
C84.91 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face and neck |
C84.92 |
Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes |
C84.93 |
Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes |
C84.94 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of axilla and upper limb |
C84.95 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb |
C84.96 |
Mature, T/NK-cell lymphomas, unspecified, intrapelvic lymph nodes |
C84.97 |
Mature T/NK-cell lymphomas, unspecified, spleen |
C84.98 |
Mature T/NK-cell lymphomas, unspecified, lymph nodes of multiple sites |
C84.99 |
Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites |
C84.Z0 |
Other mature T/NK-cell lymphomas, unspecified site |
C84.Z1 |
Other mature T/NK-cell lymphomas, lymph nodes of head, face and neck |
C84.Z2 |
Other mature T/NK-cell lymphomas, intrathoracic lymph nodes |
C84.Z3 |
Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes |
C84.Z4 |
Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb |
C84.Z5 |
Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb |
C84.Z6 |
Other mature T/NK-cell lymphomas, intrapelvic lymph nodes |
C84.Z7 |
Other mature T/NK-cell lymphomas, spleen |
C84.Z8 |
Other mature T/NK-cell lymphomas, lymph nodes of multiple sites |
C84.Z9 |
Other mature T/NK-cell lymphomas, 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 of 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 |
C86.1 |
Hepatosplenic T-cell lymphoma |
C86.2 |
Enteropathy-type (intestinal) T-cell lymphoma |
C86.5 |
Angioimmunoblastic T-cell lymphoma |
C88.0 |
Waldenström macroglobulinemia |
C88.4 |
Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma) |
C90.00 |
Multiple myeloma not having achieved remission |
C90.02 |
Multiple myeloma in relapse |
C90.10 |
Plasma cell leukemia not having achieved remission |
C90.12 |
Plasma cell leukemia in relapse |
C90.20 |
Extramedullary plasmacytoma not having achieved remission |
C90.22 |
Extramedullary plasmacytoma in relapse |
C90.30 |
Solitary plasmacytoma not having achieved remission |
C90.32 |
Solitary plasmacytoma in relapse |
C91.10 |
Chronic lymphocytic leukemia of B-cell type not having achieved remission |
C91.12 |
Chronic lymphocytic leukemia of B-cell type in relapse |
C91.50 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission |
C91.52 |
Adult T-cell lymphoma/leukemia (HTLV-1-associated) in relapse |
D47.Z1 |
Post-transplant lymphoproliferative disorder (PTLD) |
E85.3 |
Secondary systemic amyloidosis |
E85.4 |
Organ-limited amyloidosis |
E85.81 |
Light chain (AL) amyloidosis |
E85.89 |
Other amyloidosis |
E85.9 |
Amyloidosis, unspecified |
Z85.71 |
Personal history of Hodgkin lymphoma |
Z85.79 |
Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues |
Z94.81 |
Bone marrow transplant status |
Z94.89 |
Other transplanted organ and tissue status |
Z94.9 |
Transplanted organ and tissue status, unspecified |
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 Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/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/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, 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 |