Medical Policy

Effective Date:04/01/2015 Title:Blincyto (Blinatumomab)
Revision Date:01/01/2016 Document:BI477:00
CPT Code(s):J9039
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Blincyto (Blinatumomab) requires prior authorization.

Blincyto is used to treat a specific type of leukemia
Medical Statement

Blincyto (Blinatumomab) is considered medically necessary for patients who meet the following:

1)    Diagnosis of Philadelphia chromosome-negative (Ph-) relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL)   OR

2)    Diagnosis of Philadelphia chromosome-positive (Ph+) disease refractory to tyrosine kinase inhibitor therapy.

Codes Used in this BI:

J9039             Injection, Blinatumomab, 1mcg (Blincyto) effective 1/1/2016

Limits
Intentially left empty
Reference

1)    Blincyto Prescribing Information.  Amgen.  December 2014.

2)    NCCN Compendium.  Accessed online 3/2/2015.

3)    Clinical Pharmacology.  Accessed online 3/2/2015.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.