Marqibo® (vincristine – liposome)
Authorization form
Traditional, Optimized & Medicaid (11/2018)
No prior authorization is required for Medicare Part B
No prior authorization required for:
- Emergency room
- Inpatient
- Skilled nursing facility
Injectable auth/billing notes:
Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
Code(s): J9371
Benefit: Medical
Notes: Treatment of acute lymphoblatic leukemia (ALL)