Gazyva (obinutuzumab) for Non-oncologic Uses. Medical Policy MP 5.01.673 Gazyva (obinutuzumab) for Non-oncologic Uses DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general

Blue Cross of Idaho · PayerPolicy · BCIDAHO-05-01-673

Summary of the payer’s published policy. Not a coverage determination — confirm with Blue Cross of Idaho before submitting.

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Codes in this policy

Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.

Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
J9301	HCPCS	Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug.