The requested Part B medication will be approved when BOTH of the following are met:

1. ONE of the following: 
   1. There is an applicable national coverage determination (NCD) or local coverage determination (LCD) from the Medicare Administrative Contractor (MAC) for the jurisdiction and the patient meets all of the requirements listed within the NCD or LCD OR
   2. There is NOT an applicable NCD or LCD and the requested medication is being used according to FDA labeling or in accordance with a CMS supported compendia (i.e., NCCN, Clinical Pharmacology, Lexicomp Lexi-Drugs, Merative Micromedex, & AHFS-DI) or published peer-reviewed literature AND
2. ONE of the following: 
   1. The requested medication is being evaluated for approval for the first time OR
   2. The request is for continuation of therapy and the patient has shown beneficial response to therapy

Length of Approval: See Table 1 below

NOTES: 

• Length of approval may be shorter due to provider network participation status.

*See separate medical drug policies for the following drugs: Amvuttra, Onpattro and Oxlumo.

12/11/2024:

• Trastuzumab
  • Removed HCPCS code Q5114 for Ogivri
  • Added HCPCS code Q5116 for Trazimera
• Long-Acting Colony Stimulating Factors 
  • Added HCPCS code Q5108 for Fulphila
  • Added HCPCS code Q5122 for Nyvepria
  • Removed HCPCS code Q5111 for Udenyca, Udenyca Onbody
  • Removed HCPCS code Q5120 for Ziextenzo
• Immune Globulins
  • Removed HCPCS code J1599 for Alyglo
  • Removed HCPCS code J1554 for Asceniv
  • Removed HCPCS code J1556 for Bivigam
  • Removed HCPCS code J1555 for Cuvitru
  • Removed HCPCS code J1572 for Flebogamma
  • Removed HCPCS code J1557 for Gammaplex
  • Removed HCPCS code J1576 for Panzyga