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Tremfya® (guselkumab)
Policy Number: PH-90310
Intravenous
Last Review Date: 04/07/2025
Date of Origin: 08/29/2017
Dates Reviewed: 08/2017, 04/2018, 08/2018, 08/2019, 08/2020, 08/2021, 08/2022, 08/2023, 10/2024, 03/2025, 04/2025
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. |
- Length of Authorization
Ulcerative Colitis:
Initial coverage will be provided for 11 weeks (for 3 intravenous doses) as induction therapy.
Crohn’s Disease:
Initial coverage will be provided for 11 weeks (for 3 intravenous doses) as induction therapy.
- Dosing Limits
Max Units (per dose and over time) [HCPCS Unit]:
- Ulcerative Colitis
- 200 billable units every 28 days
- Crohn’s Disease
- 200 billable units every 28 days
- Initial Approval Criteria 1
Coverage is provided in the following conditions:
- Patient is at least 18 years of age; AND
- Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
- Patient is up to date with all age-appropriate vaccinations, in accordance with current vaccination guidelines, prior to initiating therapy; AND
Universal Criteria 1
- Patient has been evaluated and screened for the presence of latent tuberculosis (TB) infection prior to initiating treatment and will receive ongoing monitoring for the presence of TB during treatment; AND
- Patient does not have an active infection, including clinically important localized infections; AND
- Patient will not receive live vaccines during therapy; AND
- Patient is not on concurrent treatment with another biologic therapy or targeted synthetic therapy; AND
Ulcerative Colitis (UC) † 1,37,38,44
- Documented moderate to severe active disease; AND
- Documented failure or ineffective response to a minimum 3-month trial of conventional therapy [aminosalicylates, corticosteroids, or immunomodulators (e.g., azathioprine, 6-mercaptopurine, methotrexate, etc.)] at maximum tolerated doses, unless there is a contraindication or intolerance to use; OR
- Documented failure, contraindication, or ineffective response at maximum tolerated doses to a minimum 3-month trial of a TNF modifier such as adalimumab, golimumab, or infliximab; OR
- Patient is already established on a biologic or targeted synthetic therapy for the treatment of UC
Crohn’s Disease (CD) † 1,47-49
- Documented moderate to severe active disease; AND
- Documented failure, contraindication, or ineffective response at maximum tolerated doses to a minimum 3-month trial of corticosteroids or immunomodulators (e.g. azathioprine, 6-mercaptopurine, or methotrexate); OR
- Documented failure, contraindication, or ineffective response at maximum tolerated doses to a minimum 3-month trial of a TNF modifier such (e.g., adalimumab, certolizumab, or infliximab); OR
- Patient has evidence of high-risk disease for which corticosteroids or immunomodulators are inadequate and biologic therapy is necessary; OR
- Patient is already established on biologic or targeted synthetic therapy for the treatment of CD
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
- Renewal Criteria 1
Coverage cannot be renewed.
- Dosage/Administration 1
Indication |
Dose |
Ulcerative Colitis |
Induction: Administer 200 mg intravenously at Week 0, Week 4, and Week 8. **NOTE: Use the lowest effective recommended dosage to maintain therapeutic response. |
Crohn’s Disease |
Induction:
**NOTE: Use the lowest effective recommended dosage to maintain therapeutic response. |
- Billing Code/Availability Information
HCPCS Code(s):
- J1628 - Injection, guselkumab, 1 mg; 1 billable unit = 1 mg
(*Note: CMS generally creates codes for products themselves, without specifying a route of administration in the code descriptor, as there might be multiple routes of administration for the same product. Drugs that fall under this category should be billed with either the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for subcutaneous injection of the drug.)
NDC(s):
- Intravenous
- Tremfya 200 mg/20 mL (10 mg/mL) single-dose vial: 57894-0650-xx
- References
- Tremfya [package insert]. Horsham, PA; Janssen Biotech, Inc.; March 2025. Accessed March 2025.
- Langley RG, Tsai TF, Flavin S, et al. Efficacy and safety of guselkumab in patients with psoriasis who have an inadequate response to ustekinumab: Results of the randomized, double-blind, Phase 3 NAVIGATE trial. Br J Dermatol. 2017 Jun 21.
- Blauvelt A, Papp KA, Griffiths CE, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: Results from the phase III, double-blinded, placebo- and active comparator-controlled VOYAGE 1 trial. J Am Acad Dermatol. 2017 Mar;76(3):405-417.
- Reich K, Armstrong AW, Foley P, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: Results from the phase III, double-blind, placebo- and active comparator-controlled VOYAGE 2 trial. J Am Acad Dermatol. 2017 Mar;76(3):418-431
- Hsu S, Papp KA, Lebwohl MG, et al. Consensus guidelines for the management of plaque psoriasis. Arch Dermatol. 2012 Jan;148(1):95-102.
- Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008 May;58(5):826-50.
- Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol 2008 May;58(5):851-64.
- National Institute for Health and Care Excellence. NICE 2008. Infliximab for the treatment of adults with psoriasis. Published 23 January 2008. Technology Appraisal Guidance [TA134]. https://www.nice.org.uk/guidance/ta134/resources/infliximab-for-the-treatment-of-adults-with-psoriasis-pdf-82598193811141.
- Smith CH, Jabbar-Lopez ZK, Yiu ZK, et al. British Association of Dermatologists guidelines for biologic therapy for psoriasis 2017. Br J Dermatol. 2017 Sep;177(3):628-636. doi: 10.1111/bjd.15665.
- Armstrong AW, Siegel MP, Bagel J, et al. From the Medical Board of the National Psoriasis Foundation: Treatment targets for plaque psoriasis. J Am Acad Dermatol. 2017 Feb; 76(2):290-298. doi: 10.1016/j.jaad.2016.10.017.
- Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol 2019; 80:1029. https://doi.org/10.1016/j.jaad.2018.11.057.
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- Armstrong AW, Reich K, Foley P, et al. Improvement in Patient-Reported Outcomes (Dermatology Life Quality Index and the Psoriasis Symptoms and Signs Diary) with Guselkumab in Moderate-to-Severe Plaque Psoriasis: Results from the Phase III VOYAGE 1 and VOYAGE 2 Studies. Am J Clin Dermatol. 2019;20(1):155-164. doi:10.1007/s40257-018-0396-z.
- Ferris LK, Ott E, Jiang J, et al. Efficacy and safety of guselkumab, administered with a novel patient-controlled injector (One-Press), for moderate-to-severe psoriasis: results from the phase 3 ORION study. J Dermatolog Treat. 2020;31(2):152-159. doi:10.1080/09546634.2019.1587145.
- American Academy of Dermatology Work Group. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74.
- Ramiro S, Smolen JS, Landewé R, et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2016;75:490-498 doi:10.1136/annrheumdis-2015-208466.
- National Institute for Health and Care Excellence. NICE 2017. Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs. Published 24 May 2017. Technology Appraisal Guidance [TA445]. https://www.nice.org.uk/guidance/ta445.
- Deodhar A, Helliwell PS, Boehncke WH, et al. Guselkumab in patients with active psoriatic arthritis who were biologic-naive or had previously received TNFα inhibitor treatment (DISCOVER-1): a double-blind, randomised, placebo-controlled phase 3 trial [published correction appears in Lancet. 2020 Apr 4;395(10230):1114]. Lancet. 2020;395(10230):1115-1125. doi:10.1016/S0140-6736(20)30265-8.
- Mease PJ, Rahman P, Gottlieb AB, et al. Guselkumab in biologic-naive patients with active psoriatic arthritis (DISCOVER-2): a double-blind, randomised, placebo-controlled phase 3 trial [published correction appears in Lancet. 2020 Apr 4;395(10230):1114]. Lancet. 2020;395(10230):1126-1136. doi:10.1016/S0140-6736(20)30263-4.
- Smith CH, Yiu ZZN, Bale T, et al; British Association of Dermatologists’ Clinical Standards Unit. British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol. 2020 Oct;183(4):628-637. Doi: 10.1111/bjd.19039.
- National Institute for Health and Care Excellence. NICE 2013. Psoriasis. Published 06 August 2013. Quality standard [QS40]. https://www.nice.org.uk/guidance/qs40.
- Menter A, Gelfand JM, Connor C, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol 2020; 82:1445.
- Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Annals of the Rheumatic Diseases 2020 Jun;79(6):700-712. doi: 10.1136/annrheumdis-2020-217159.
- Mease PJ. Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11:S64-85. doi: 10.1002/acr.20577.
- Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019 Jan;71(1):5-32. doi: 10.1002/art.40726.
- National Institute for Health and Care Excellence (NICE). Guselkumab for treating moderate to severe plaque psoriasis. Technology appraisal guidance. Published: 13 June 2018. www.nice.org.uk/guidance/ta521.
- National Institute for Health and Care Excellence. NICE 2017. Psoriasis: assessment and management. Published 24 October 2012. Clinical guideline [CG153]. https://www.nice.org.uk/guidance/CG153.
- Elmets CA, Lim HW, Stoff B, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. 2019 Sep;81(3):775-804. Doi: 10.1016/j.jaad.2019.04.042.
- Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020 Jan;82(1):161-201. Doi: 10.1016/j.jaad.2019.08.049.
- Tucker L, Allen A, Chandler D, et al. The 2022 British Society for Rheumatology guideline for the treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford). 2022 Aug 30;61(9):e255-e266. doi: 10.1093/rheumatology/keac295.
- Elmets CA, Korman NL, Prater EF, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol 2021 Feb; 84(2):432-470. Doi: 10.1016/j.jaad.2020.07.087
- Gossec L, Kerschbaumer A, Ferreira RJO, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update. Ann Rheum Dis. 2024 May 15;83(6):706-719. doi: 10.1136/ard-2024-225531. PMID: 38499325
- Foley P, Gebaur K, Sullivan J, et al. Australian consensus: Treatment goals for moderate to severe psoriasis in the era of targeted therapies – Adult patients. Australas J Dermatol. 2023 Nov;64(4):467-487. doi:10.1111/ajd.14138
- Rubin DT, Ananthakrishnan AN, Siegel CA, et al. ACG clinical guideline: ulcerative colitis in adults. Am J Gastroenterol. 2019 Mar;114(3):384-413.
- National Institute for Health and Care Excellence. NICE 2019. Ulcerative colitis: management. Published 03 May 2019. NICE guideline [NG130]. https://www.nice.org.uk/guidance/ng130
- Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis. Gastroenterology. 2020;158(5):1450-1461. doi:10.1053/j.gastro.2020.01.006.
- Raine T, Bonovas S, Burisch J, et al. ECCO Guidelines on therapeutics in ulcerative colitis: medical treatment. J Crohns Colitis. 2022 Jan 28. 16 (1):2-17. Doi: 10.1093/ecco-jcc/jjab178
- Lewis JD, Chuai S, Nessel L, et al. Use of the Non-invasive Components of the Mayo Score to Assess Clinical Response in Ulcerative Colitis. Inflamm Bowel Dis. 2008 Dec; 14(12): 1660–1666. doi: 10.1002/ibd.20520
- Paine ER. Colonoscopic evaluation in ulcerative colitis. Gastroenterol Rep (Oxf). 2014 Aug; 2(3): 161–168.
- Walsh AJ, Bryant RV, Travis SPL. Current best practice for disease activity assessment in IBD. Nature Reviews Gastroenterology & Hepatology 13, 567–579 (2016) doi:10.1038/nrgastro.2016.128
- Peyrin-Biroulet L, Allegretti JR, Rubin DT, et al. Guselkumab in Patients With Moderately to Severely Active Ulcerative Colitis: QUASAR Phase 2b Induction Study. Gastroenterology, Volume 165, Issue 6, 1443-1457.
- Singh S, Ananthakrishnan AN, Nguyen NH, et al. AGA Clinical Practice Guideline on the Role of Biomarkers for the Management of Ulcerative Colitis. Gastroenterology. 2023 Mar;164(3):344-372. doi: 10.1053/j.gastro.2022.12.007. PMID: 36822736.
- Singh S, Loftus EV Jr, Limketkai BN, et al. AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis. Gastroenterology. 2024 Dec;167(7):1307-1343. doi: 10.1053/j.gastro.2024.10.001. PMID: 39572132.
- Kornbluth, A, Sachar, DB; Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010 Mar;105(3):501-23.
- Tiwari V, Brent LH. Psoriatic Arthritis. [Updated 2024 Jan 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK547710/. Accessed February 12, 2025.
- Lichtenstein GR, Loftus EV, Isaacs KI, et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol 2018; 113:481–517; doi: 10.1038/ajg.2018.27.
- Feuerstein JD, Ho EY, Shmidt E, et al. AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease. Gastroenterology. 2021 Jun;160(7):2496-2508. doi: 10.1053/j.gastro.2021.04.022. PMID: 34051983; PMCID: PMC8988893.
- Gordon H, Minozzi S, Kopylov U, et al. ECCO Guidelines on Therapeutics in Crohn’s Disease: Medical Treatment, Journal of Crohn's and Colitis, 2024; https://doi.org/10.1093/ecco-jcc/jjae091.
- Ananthakrishnan AN, Alder J, Chachu KA, et al. AGA Clinical Practice Guideline on the Role of Biomarkers for the Management of Crohn’s Disease. Gastroenterology. 2023 Dec;165(6):1367-1399. doi: 10.1053/j.gastro.2023.09.029. PMID: 37981354.
- Ranasinghe IR, Tian C, Hsu R. Crohn Disease. [Updated 2024 Feb 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK436021/. Accessed March 24, 2025.
- Danese S, Panaccione R, Feagan BG, et al; GALAXI-1 Study Group. Efficacy and safety of 48 weeks of guselkumab for patients with Crohn's disease: maintenance results from the phase 2, randomised, double-blind GALAXI-1 trial. Lancet Gastroenterol Hepatol. 2024 Feb;9(2):133-146. doi: 10.1016/S2468-1253(23)00318-7. Epub 2023 Dec 14. PMID: 38104569.
- Panaccione R, Danese S, Feagan BG, et al. Efficacy and safety of guselkumab therapy in patients with moderately to severely active Crohn’s disease: results of the GALAXI 2 & 3 phase 3 studies. Gastroenterology. 2024;166(5 Suppl):1057b-1057b2.
- Panaccione R, Hart A, Steinwurz F, et al. Efficacy and safety of subcutaneous guselkumab induction therapy in patients with moderately to severely active Crohn’s disease: results through week 48 from the phase 3 GRAVITI study. Oral presentation 72. In: American College of Gastroenterology 2024 Annual Scientific Meeting; October 25-30, 2024; Philadelphia, PA, USA.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
K50.00 |
Crohn’s disease of small intestine without complications |
K50.011 |
Crohn’s disease of small intestine with rectal bleeding |
K50.012 |
Crohn’s disease of small intestine with intestinal obstruction |
K50.013 |
Crohn’s disease of small intestine with fistula |
K50.014 |
Crohn’s disease of small intestine with abscess |
K50.018 |
Crohn’s disease of small intestine with other complication |
K50.019 |
Crohn’s disease of small intestine with unspecified complications |
K50.10 |
Crohn’s disease of large intestine without complications |
K50.111 |
Crohn’s disease of large intestine with rectal bleeding |
K50.112 |
Crohn’s disease of large intestine with intestinal obstruction |
K50.113 |
Crohn’s disease of large intestine with fistula |
K50.114 |
Crohn’s disease of large intestine with abscess |
K50.118 |
Crohn’s disease of large intestine with other complication |
K50.119 |
Crohn’s disease of large intestine with unspecified complications |
K50.80 |
Crohn’s disease of both small and large intestine without complications |
K50.811 |
Crohn’s disease of both small and large intestine with rectal bleeding |
K50.812 |
Crohn’s disease of both small and large intestine with intestinal obstruction |
K50.813 |
Crohn’s disease of both small and large intestine with fistula |
K50.814 |
Crohn’s disease of both small and large intestine with abscess |
K50.818 |
Crohn’s disease of both small and large intestine with other complication |
K50.819 |
Crohn’s disease of both small and large intestine with unspecified complications |
K50.90 |
Crohn’s disease, unspecified, without complications |
K50.911 |
Crohn’s disease, unspecified, with rectal bleeding |
K50.912 |
Crohn’s disease, unspecified, with intestinal obstruction |
K50.913 |
Crohn’s disease, unspecified, with fistula |
K50.914 |
Crohn’s disease, unspecified, with abscess |
K50.918 |
Crohn’s disease, unspecified, with other complication |
K50.919 |
Crohn’s disease, unspecified, with unspecified complications |
K51.00 |
Ulcerative (chronic) pancolitis without complications |
K51.011 |
Ulcerative (chronic) pancolitis with rectal bleeding |
K51.012 |
Ulcerative (chronic) pancolitis with intestinal obstruction |
K51.013 |
Ulcerative (chronic) pancolitis with fistula |
K51.014 |
Ulcerative (chronic) pancolitis with abscess |
K51.018 |
Ulcerative (chronic) pancolitis with other complication |
K51.019 |
Ulcerative (chronic) pancolitis with unspecified complications |
K51.20 |
Ulcerative (chronic) proctitis without complications |
K51.211 |
Ulcerative (chronic) proctitis with rectal bleeding |
K51.212 |
Ulcerative (chronic) proctitis with intestinal obstruction |
K51.213 |
Ulcerative (chronic) proctitis with fistula |
K51.214 |
Ulcerative (chronic) proctitis with abscess |
K51.218 |
Ulcerative (chronic) proctitis with other complication |
K51.219 |
Ulcerative (chronic) proctitis with unspecified complications |
K51.30 |
Ulcerative (chronic) rectosigmoiditis without complications |
K51.311 |
Ulcerative (chronic) rectosigmoiditis with rectal bleeding |
K51.312 |
Ulcerative (chronic) rectosigmoiditis with intestinal obstruction |
K51.313 |
Ulcerative (chronic) rectosigmoiditis with fistula |
K51.314 |
Ulcerative (chronic) rectosigmoiditis with abscess |
K51.318 |
Ulcerative (chronic) rectosigmoiditis with other complication |
K51.319 |
Ulcerative (chronic) rectosigmoiditis with unspecified complications |
K51.50 |
Left sided colitis without complications |
K51.511 |
Left sided colitis with rectal bleeding |
K51.512 |
Left sided colitis with intestinal obstruction |
K51.513 |
Left sided colitis with fistula |
K51.514 |
Left sided colitis with abscess |
K51.518 |
Left sided colitis with other complication |
K51.519 |
Left sided colitis with unspecified complications |
K51.80 |
Other ulcerative colitis without complications |
K51.811 |
Other ulcerative colitis with rectal bleeding |
K51.812 |
Other ulcerative colitis with intestinal obstruction |
K51.813 |
Other ulcerative colitis with fistula |
K51.814 |
Other ulcerative colitis with abscess |
K51.818 |
Other ulcerative colitis with other complication |
K51.819 |
Other ulcerative colitis with unspecified complications |
K51.90 |
Ulcerative colitis, unspecified, without complications |
K51.911 |
Ulcerative colitis, unspecified with rectal bleeding |
K51.912 |
Ulcerative colitis, unspecified with intestinal obstruction |
K51.913 |
Ulcerative colitis, unspecified with fistula |
K51.914 |
Ulcerative colitis, unspecified with abscess |
K51.918 |
Ulcerative colitis, unspecified with other complication |
K51.919 |
Ulcerative colitis, unspecified with unspecified complications |
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 |