Zevalin® (ibritumomab tiuxetan)

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): A9543

Benefit: Medical

Notes: Radioimmunotherapy; indicated for the treatment of relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma (NHL)

Criteria for coverage:

  • See PA form for criteria for Commercial and Medicaid

  • Refer to CMS local coverage determination criteria for Part B when available.