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)