Ovarian Cancer. compendia TREATMENT OF

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1 drug & compendia TREATMENT OF Ovarian Cancer With each publication, ManagedCare Oncology s drug & Compendia highlights a single medication or a group of medications that could be utilized in the management of one of the featured oncology diseases. This section addresses such topics as: Associated ICD-9-CM codes Drugs that have been FDA-approved Drugs that are compendia-listed for off-label use based on clinical studies that suggest beneficial use in some cases Ancillary medications used in cancer treatment Reimbursement and coding information HCPCS/CPT codes and code description Current code price (AWP-based pricing) Most recent allowable (ASP + 6%), if applicable administration codes that can be utilized with each drug Associated ICD-9-CM Codes: 183 Malignant neoplasm of ovary and other uterine adnexa Excludes Douglas cul-de-sac (158.8) Ovary Fallopian tube Oviduct Uterine tube Parametrium Uterine ligament NOS Uterosacral ligament Round ligament Other specified sites of uterine adnexa Tubo-ovarian Utero-ovarian Malignant neoplasm of contiguous or overlapping sites of ovary and other uterine adnexa whose point of origin cannot be determined 36 managedcareoncology Quarter

2 FDA-Approved Medications Currently Available to Treat Ovarian Cancer generic (Brand) Name (AwP-Based Pricing) (ASP + 6%) Effective altretamine (Hexalen) J8999* Prescription drug, oral, chemotherapeutic, Not Otherwise Specified NDC-level pricing NDC-level pricing carboplatin (Paraplatin) J9045 carboplatin, 50 mg $86.00 $ , 96413, cisplatin (Platinol AQ) J9060 cisplatin, powder or solution, per 10 mg $4.33 $ , 96413, cyclophosphamide (Cytoxan) J8530 Cyclophosphamide, oral, 25 mg $2.53 $0.98 cyclophosphamide (Cytoxan) J9070 Cyclophosphamide, 100 mg $67.86 $ , 96413, doxorubicin HCl (Adriamycin) J9000 doxorubicin hydrochloride, 10 mg $12.00 $ doxorubicin HCl liposomal (Doxil) J9002 doxorubicin hydrochloride, liposomal, Doxil, 10 mg (Code no longer payable effective 7/1/13.) $ J9002 not payable by doxorubicin HCl liposomal (Doxil) gemcitabine (Gemzar) hydroxyurea (Hydrea) Q2050 doxorubicin hydrochloride, liposomal, Not Otherwise Specified, 10 mg J9201 gemcitabine hydrochloride, 200 mg J8999* Prescription drug, oral, chemotherapeutic, Not Otherwise Specified $ $ $41.54 $ NDC-level pricing NDC-level pricing hydroxyurea (Hydrea) S0176 Hydroxyurea, oral, 500 mg $1.15 S0176 not payable by melphalan (Alkeran) J8600 Melphalan, oral, 2 mg $10.55 $8.73 paclitaxel (Taxol) J9265 paclitaxel, 30 mg $15.54 $ , thiotepa (Thioplex) J9340 thiotepa, 15 mg $ $ , topotecan (Hycamtin) J9351 topotecan, 0.1 mg $7.05 $ *When billing a nonclassified medication using a CMS 1500 claim form, you must include both the HCPCS code (e.g., J8999 for Hydrea) in Column 24D and the drug name, strength and NDC (National Drug Code) in Box 19 or 24A in order to ensure appropriate reimbursement. Please note: Check with payor regarding correct placement of medication information. managedcareoncology.com 37

3 Compendia-Listed Off-Label-Use Medications Currently Available to Treat Ovarian Cancer generic (Brand) Name (AWP-Based Pricing) (ASP + 6%) Effective anastrozole (Arimidex) J8999* Prescription drug, oral, chemotherapeutic, Not Otherwise Specified NDC-level pricing NDC-level pricing anastrozole (Arimidex) S0170 Anastrozole, oral, 1 mg $13.48 S0170 not payable bacillus Calmette-Guérin (Tice BCG, Theracys) Bacillus Calmette-Guérin vaccine (BCG) for bladder cancer, live, for intravesical use $ $ bacillus Calmette-Guérin (Tice BCG, Theracys) J9031 BCG (intravesical), per installation $ $ bevacizumab (Avastin) J9035 bevacizumab, 10 mg $76.18 $ , bleomycin (Blenoxane) J9040 bleomycin sulfate, 15 units $41.40 $ , capecitabine (Xeloda) J8520 Capecitabine, oral, 150 mg $11.96 $9.69 capecitabine (Xeloda) J8521 Capecitabine, oral, 500 mg $39.88 $32.19 chlorambucil (Leukeran) J8999* Prescription drug, oral, chemotherapeutic, Not Otherwise Specified NDC-level pricing NDC-level pricing chlorambucil (Leukeran) S0172 Chlorambucil, oral, 2 mg $5.57 S0172 not payable dactinomycin (Cosmegen) J9120 dactinomycin, 0.5 mg $ $ docetaxel (Taxotere) J9171 docetaxel, 1 mg $18.26 $ epirubicin (Ellence) J9178 epirubicin HCl, 2 mg $2.69 $ , etoposide (Vepesid) J8560 Etoposide, oral, 50 mg $70.86 $55.68 etoposide (Etopophus, Toposar) J9181 etoposide, 10 mg $0.91 $ , fluorouracil (Adrucil) J9190 fluorouracil, 500 mg $3.30 $ ifosfamide (Ifex) J9208 ifosfamide, 1 g $44.09 $ , interferon alfa-2b (Intron-A) interferon alfa-n3 (Alferon N) J9214 interferon, alfa-2b, recombinant, 1 million units J9215 interferon, alfa-n3 (human leukocyte-derived), 250,000 IU $21.90 $ , $36.14 None reported 11900, irinotecan (Camptosar) J9206 irinotecan, 20 mg $10.80 $ , leuprolide acetate (Lupron) J9218 Leuprolide acetate, per 1 mg $23.57 $ melphalan (Alkeran) J9245 melphalan hydrochloride, 50 mg $1, $1, , methotrexate (Trexall) J8610 Methotrexate, oral, 2.5 mg $3.56 $1.08 methotrexate J9250 Methotrexate sodium, 5 mg $0.29 $ , 96374, 96401, 96409, methotrexate J9260 Methotrexate sodium, 50 mg $2.85 $ , 96374, 96401, 96409, mifepristone (Mifeprex) J8499* Prescription drug, oral, nonchemotherapeutic, Not Otherwise Specified NDC-level pricing NDC-level pricing 38 managedcareoncology Quarter

4 generic (Brand) Name (AWP-Based Pricing) (ASP + 6%) Effective mifepristone (Mifeprex) S0190 Mifepristone, oral, 200 mg $90.00 S0190 not payable mitoxantrone (Novantrone) J9293 mitoxantrone hydrochloride, per 5 mg $68.24 $ , oxaliplatin (Eloxatin) J9263 oxaliplatin, 0.5 mg $2.04 $ , tamoxifen (Nolvadex) J8999* Prescription drug, oral, chemotherapeutic, Not Otherwise Specified NDC-level pricing NDC-level pricing tamoxifen (Nolvadex) S0187 Tamoxifen citrate, oral, 10 mg $1.89 S0187 not payable triptorelin (Trelstar) J3315 triptorelin pamoate, 3.75 mg $ $ , vinblastine (Velban) J9360 vinblastine sulfate, 1 mg $3.18 $ vincristine (Vincasar PFS) J9370 Vincristine sulfate, 1 mg $6.61 $ vinorelbine (Navelbine) J9390 vinorelbine tartrate, per 10 mg $27.00 $ *When billing a nonclassified medication using a CMS 1500 claim form, you must include both the HCPCS code (e.g., J8999 for Hydrea) in Column 24D and the drug name, strength and NDC (National Drug Code) in Box 19 in order to ensure appropriate reimbursement. Ancillary Medications Used in Cancer Treatment generic (Brand) Name (AWP-Based Pricing) (ASP + 6%) Effective aprepitant (Emend) J8501 Aprepitant, oral, 5 mg $8.49 $6.69 granisetron (Kytril) J1626 granisetron hydrochloride, 100 mcg $3.84 $ granisetron (Kytril) Q0166 Granisetron hydrochloride, 1 mg oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at time of chemotherapy treatment, not to exceed a 24-hour dosage regimen $59.01 $2.54 granisetron (Kytril) S0091 Granisetron hydrochloride, 1 mg (For circumstances falling under the statute, use Q0166.) $59.01 S0091 not payable ondansetron (Zofran) J2405 ondansetron hydrochloride, per 1 mg $0.36 $ , ondansetron (Zofran) Q0162 Ondansetron 1 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen $6.05 $0.04 ondansetron (Zofran) S0119 Ondansetron, oral, 4 mg (For circumstances falling under the statute, use HCPCS code Q0162.) $24.20 S0119 not payable palonosetron (Aloxi) J2469 palonosetron HCl, 25 mcg $45.96 $ managedcareoncology.com 39

5 CPT Code Descriptions CPT Code Code Description intralesional; up to and including seven lesions intralesional; more than seven lesions Bladder instillation of anticarcinogenic agent (including retention time) Chemotherapy administration, subcutaneous or intramuscular; nonhormonal antineoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic Chemotherapy administration, intravenous push technique; single or initial substance/drug Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure.) (Use in conjunction with ) Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug References HCPCS Level II Expert Current Procedural Terminology (CPT) American Medical Association. ICD-9-CM for Professionals. Vol. 1 and 2. Chicago: AMA Press; RJ Health Systems International, LLC. The Drug Reimbursement Coding and Pricing Guide. Vol. 11, Number 4, Fourth Quarter FDA-approved indication (product prescribing information). CMS (Centers for & Medicaid Services) Fourth Quarter 2013 Effective Dates. CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. This information was supplied by RJ Health Systems International, LLC, located in Rocky Hill, Conn. 40 managedcareoncology Quarter

6 Oncology-Related HCPCS Codes This reference chart will assist the oncology office (office manager, oncology nurse, physician and ancillary staff) and payor with the appropriate codes to utilize when billing or reimbursing for medication(s). generic (Brand) Name HCPCS Code Code Description FDA-Approved Uses Compendia-Listed Off-Label Uses Current Code Price (AWP-Based Pricing)* Effective 10/1/13 Allowable (ASP + 6%) Effective 10/1/13-12/31/13 Possible CPT Admin azacitidine (Vidaza) J9025 azacitidine, 1 mg Chronic myeloid leukemia (205.1_) Low grade myelodysplastic syndrome lesions (238.72) High grade myelodysplastic syndrome lesions (238.73) Myelodysplastic syndrome with 5q deletion (238.74) Myelodysplastic syndrome, unspecified (238.75) Malignant neoplasm of specified parts of peritoneum (158.8) Malignant neoplasm of peritoneum, unspecified (158.9) Malignant neoplasm of pleura (163) Malignant neoplasm of heart (164.1) Acute myeloid leukemia (205.0_) Other thalassemia (282.49) Sickle-cell disease, unspecified (282.60) Hb-SS disease without crisis (282.61) Hb-SS disease with crisis (282.62) Sickle-cell/Hb-C disease without crisis (282.63) Sickle-cell/Hb-C disease with crisis (282.64) Other sickle-cell disease without crisis (282.68) Other sickle-cell disease with crisis (282.69) $6.59 $ , 96409, brentuximab vedotin (Adcetris) J9042 brentuximab vedotin, 1 mg Anaplastic large cell lymphoma (200.6_) Hodgkin s disease (201._) $ $ cabazitaxel (Jevtana) J9043 cabazitaxel, 1 mg Malignant neoplasm of prostate (185) $ $ cetuximab (Erbitux) J9055 cetuximab, 10 mg Malignant neoplasm of lip (140._) Malignant neoplasm of tongue (141._) Malignant neoplasm of major salivary glands (142._) Malignant neoplasm of gum (143._) Malignant neoplasm of floor of mouth (144._) Malignant neoplasm of other and unspecified parts of mouth (145._) Malignant neoplasm of oropharynx (146._) Malignant neoplasm of nasopharynx (147._) Malignant neoplasm of hypopharynx (148._) Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx (149._) Malignant neoplasm of colon (153._) Malignant neoplasm of rectum, rectosigmoid junction and anus (154._) Malignant neoplasm of nasal cavities, middle ear and accessory sinuses (160._) Malignant neoplasm of larynx (161._) Malignant neoplasm of head, neck and face (195.0) Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck (196.0) Malignant neoplasm of trachea, bronchus and lung (162._) $61.14 $ , managedcareoncology.com 41

7 generic (Brand) Name HCPCS Code Code Description FDA-Approved Uses Compendia-Listed Off-Label Uses Current Code Price (AwP-Based Pricing)* Effective 10/1/13 Allowable (ASP + 6%) Effective 10/1/13-12/31/13 Possible CPT Admin dactinomycin (Cosmegen) J9120 dactinomycin, 0.5 mg Malignant neoplasm of retroperitoneum (158.0) Malignant neoplasm of bone and articular cartilage (170._) Malignant neoplasm of connective and other soft tissue (171._) Malignant neoplasm of placenta (181) Malignant neoplasm of testis (186._) Malignant neoplasm of kidney, except pelvis (189.0) Neoplasm of uncertain behavior of placenta (236.1) Malignant melanoma of skin (172._) Kaposi s sarcoma (176._) Malignant neoplasm of ovary (183._) Malignant neoplasm of vagina (184._) Malignant neoplasm of penis and other male genital organs (187._) Malignant neoplasm of eye (190._) Complications of transplanted kidney (996.81) Complications of transplanted heart (996.83) $ $ degarelix (Firmagon) J9155 degarelix, 1 mg Malignant neoplasm of prostate (185) $6.31 $ ixabepilone (Ixempra) J9207 ixabepilone, 1 mg Malignant neoplasm of female breast (174._) Malignant neoplasm of male breast (175._) Malignant neoplasm of prostate (185) $79.85 $ , panitumumab (Vectibix) J9303 panitumumab, 10 mg Malignant neoplasm of colon (153._) Malignant neoplasm of rectum, rectosigmoid junction and anus (154._) Malignant neoplasm of trachea, bronchus and lung (162._) $ $ , rituximab (Rituxan) J9310 rituximab, 100 mg Reticulosarcoma (200.0_) Lymphosarcoma (200.1_) Burkitt s tumor or lymphoma (200.2_) Marginal zone lymphoma (200.3_) Mantle cell lymphoma (200.4_) Primary central nervous system lymphoma (200.5_) Large cell lymphoma (200.7_) Other named variants of lymphosarcoma and reticulosarcoma (200.8_) Nodular lymphoma (202.0_) Leukemic reticuloendotheliosis (202.4_) Other malignant lymphomas (202.8_) Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue (202.9_) Chronic lymphoid leukemia, without mention of having achieved remission (204.1_) Polyarteritis nodosa (446.0) Wegener s granulomatosis (446.4) Rheumatoid arthritis (714.0) Felty s syndrome (714.1) Other rheumatoid arthritis with visceral or systemic involvement (714.2) Hodgkin s paragranuloma (201.0_) Hodgkin s granuloma (201.1_) Hodgkin s sarcoma (201.2_) Hodgkin s disease, lymphocytichistiocytic predominance (201.4_) Acute lymphoid leukemia (204.0_) Post-transplant lymphoproliferative disorder (PTLD) (238.77) Macroglobulinemia (273.3) Chronic graft-versus-host disease (279.52) Acute or chronic graft-versus-host disease (279.53) Autoimmune hemolytic anemias (283.0) Von Willebrand disease (286.4) Acquired coagulation factor deficiency (286.7) Other and unspecified coagulation defects (286.9) Immune thrombocytopenic purpura (287.31) Thrombotic microangiopathy (446.6) Pemphigus (694.4) Systemic lupus erythematosus (710.0) Enlargement of lymph nodes (785.6) Malignant ascites (789.51) $ $ , *The code price is based on the HCPCS code description. HCPCS (Healthcare Common Procedure Coding System) codes are a component of CMS (Centers for & Medicaid Services). The code price is an AWP-based pricing methodology developed by RJ Health Systems International, LLC, Rocky Hill, Conn. Oncology-Related J-Code References HCPCS Level II Expert Current Procedural Terminology (CPT) American Medical Association. ICD-9-CM for Professionals. Vol. 1 and 2. Chicago: AMA Press; Full prescribing information for each drug listed. Powered by RJ Health Systems International, LLC, Rocky Hill, Conn. CMS (Centers for & Medicaid Services) Fourth Quarter 2013 Effective Dates. CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. This information was supplied by RJ Health Systems International, LLC, located in Rocky Hill, Conn. Current code prices are effective as of 10/1/ managedcareoncology Quarter

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