Bristol Myers Squibb is committed to helping appropriate patients get access to our medications by providing access and reimbursement support services.

This information is intended for U.S. healthcare professionals and/or healthcare professionals involved in healthcare reimbursement.

Billing and
Diagnosis Codes

Previously Treated Marginal Zone Lymphoma

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

Reimbursement and Coding Guide for REVLIMID
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National Drug Codes (NDC)1Issued by the FDA
59572-0402-28

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2.5 mg bottles of 28 capsules

59572-0402-00

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2.5 mg bottles of 100 capsules

59572-0405-28

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5 mg bottles of 28 capsules

59572-0405-00

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5 mg bottles of 100 capsules

59572-0410-28

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10 mg bottles of 28 capsules

59572-0410-00

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10 mg bottles of 100 capsules

59572-0415-21

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15 mg bottles of 21 capsules

59572-0415-00

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15 mg bottles of 100 capsules

59572-0420-21

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20 mg bottles of 21 capsules

59572-0420-00

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20 mg bottles of 100 capsules

59572-0425-21

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25 mg bottles of 21 capsules

59572-0425-00

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25 mg bottles of 100 capsules

International Classification of Diseases, Tenth Revision, Clinical Modification Diagnosis Codes (ICD-10-CM)2

C88.4

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Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT)

Prescribers and pharmacies must be certified with the REVLIMID REMS® program by enrolling and complying with the REMS requirements; pharmacies must only dispense to patients who are authorized to receive REVLIMID. The REMS-Pharmacy Network list includes specialty pharmacies that are contracted to fill prescriptions for restricted distribution programs for Bristol Myers Squibb.

Pharmacy Phone Fax
ACRO Pharmaceutical Services 1-800-906-7798 1-877-381-3806
Accredo Specialty Pharmacy 1-877-732-3431 1-800-590-1021
Advanced Care Scripts (ACS) 1-877-985-6337 1-866-679-7131
Aetna Specialty Pharmacy 1-866-782-2779 1-860-900-7994
AllianceRx Walgreens Prime 1-888-347-3416 1-877-231-8302
Amber Pharmacy 1-888-763-5517 1-402-896-4862
Avella Specialty Pharmacy 1-877-546-5779 1-877-546-5780
Biologics Inc. 1-800-850-4306 1-800-823-4506
BioPlus Specialty Pharmacy 1-888-292-0744 1-800-269-5493
BriovaRx, an OptumRx® Specialty 1-888-432-2797 1-866-306-5231
Cardinal Health Specialty Pharmacy 1-888-662-6779 1-877-800-4790
CareMed Specialty Pharmacy 1-877-227-3405 1-877-542-2731
CIGNA Specialty Pharmacy 1-800-351-3606 1-800-351-3616
CVS Specialty Pharmacy Customer Care 1-800-237-2767 1-800-323-2445
Diplomat Specialty Pharmacy 1-877-977-9118 1-800-550-6272
Exactus Pharmacy Solutions, Inc. (WellCare) 1-866-458-9246 1-866-458-9245
Humana Specialty Pharmacy 1-800-486-2668 1-877-405-7940
Kroger Specialty Pharmacy 1-888-315-3395 1-888-315-3270
Magellan Rx Pharmacy/ICORE 1-866-554-2673 1-866-364-2673
McKesson Specialty Pharmacy: Veterans Affairs Rx service 1-855-637-9433 1-855-637-9446
Onco360 1-877-662-6633 1-877-662-6355
TNH Advanced Specialty Pharmacy 1-877-849-9591 1-855-356-1096
Upstate Pharmacy 1-800-314-4655 1-800-314-7756
US Bioservices 1-877-757-0667 1-888-899-0067

Above information is accurate as of 05/21.

The REVLIMID distribution program includes extended payment terms to Bristol Myers Squibb authorized REVLIMID distributors. Healthcare providers and institutions should contact their REVLIMID distributor to understand specific payment terms that may be available to them from their distributor.

Please see U.S. Full Prescribing Information for REVLIMID, including Boxed WARNINGS.

FDA Approval Letter as Posted by the FDA:

For the treatment of adult patients with previously treated marginal zone lymphoma in combination with a rituximab product

View Letter

Please see U.S. Full Prescribing Information for REVLIMID, including Boxed WARNINGS.

Coding for REVLIMID is dependent on the insurer and the care setting in which the drug will be administered. Oncology practices need to make coding decisions based on the diagnosis and treatment of each patient and the specific insurer requirements.

Please see U.S. Full Prescribing Information for REVLIMID, including Boxed WARNINGS.

*Healthcare providers should code healthcare claims based upon the service that is rendered, the patient's medical record, the coding requirements of each health insurer, and best coding practices. Coding guidance provided under this heading does not provide a guarantee of reimbursement and should be considered together with all applicable coding guidance and standards. All of the coding information presented by this website is applicable to outpatient procedures only.

References:

  1. REVLIMID [package insert]. Princeton, NJ: Bristol-Myers Squibb Company.
  2. Centers for Medicare & Medicaid Services. ICD-10-CM tabular list of diseases and injuries. Accessed March 8, 2021. https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

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©2021 Bristol-Myers Squibb Company. All rights reserved. Access Support is a registered trademark of Bristol-Myers Squibb Company. REVLIMID® and REVLIMID REMS® are registered trademarks of Celgene Corporation, a Bristol Myers Squibb company.

Use of the information on this site is subject to the terms of our Legal Notice and Privacy Statement. The coding, coverage, and payment information contained within this website is current as of 05/21.

2003-US-2100005 05/21