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Product Distribution

Sample Letters and Checklists*

Billing and Coding Information

BESPONSA® (inotuzumab ozogamicin) & MYLOTARGTM (gemtuzumab ozogamicin)

BIOSIMILARS: RETACRITTM (epoetin alfa-epbx) & NIVESTYMTM (filgrastim-aafi)

Please see full Prescribing Information for BESPONSA, including BOXED WARNING, or visit BESPONSAhcp.com.

Please see full Prescribing Information for MYLOTARG, including BOXED WARNING, or visit MYLOTARGhcp.com.

Please see full Prescribing Information for RETACRIT, including BOXED WARNING and Medication Guide, or visit RETACRIThcp.com.

The information provided here is intended for informational purposes only, and is not a comprehensive description of potential coding requirements for BESPONSA, MYLOTARG, RETACRIT, and NIVESTYM. Coding and coverage policies change periodically and often without warning. The healthcare provider is solely responsible for determining coverage and reimbursement parameters and accurate and appropriate coding for treatment of his/her own patients. The information provided in this section should not be considered a guarantee of coverage or reimbursement for BESPONSA, MYLOTARG, RETACRIT, and NIVESTYM.

The sample forms are intended as a reference for billing and coding of BESPONSA, MYLOTARG, RETACRIT, and NIVESTYM. These forms are not intended to be directive, and the use of the recommended codes does not guarantee reimbursement. Healthcare providers may deem other codes or policies more appropriate and should select the coding options that most accurately reflect their internal guidelines, payer requirements, practice patients, and the services rendered.

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