Rituxan® (rituximab)

Authorization forms

Traditional, Optimized, & Medicaid (09/2018)

Medicare Part B (01/2019)

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): J9310

Benefit: Medical

Notes:

  • 10mg/mL
  • When authorized, Rituxan® will be approved at a dose of 375mg/m2 for all indications except RA.
  • Approved dosing for RA is 1,000mg every two weeks.

Length of initial authorization: 3 months.

Length of continuation authorization: 12 months.