| Effective Date:01/01/2018 |
Title:Besponsa
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| Revision Date:05/01/2018
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Document:BI562:00
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| CPT Code(s):C9028, J9229
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Public Statement
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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)
Besponsa (inotuzumab
ozogamicin) requires prior authorization.
2)
Besponsa is
used to treat a type of leukemia.
3)
Besponsa is
covered under the medical benefit as a specialty drug.
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Medical Statement
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Besponsa (inotuzumab ozogamicin) is considered medically necessary for adults
age 18 and older in the following conditions:
1) Relapsed/refractory Philadelphia chromosome-positive B-cell precursor
acute lymphoblastic leukemia (ALL) in tyrosine kinase inhibitor (TKI)
intolerant/refractory patients OR
2) Relapsed/refractory
Philadelphia chromosome-negative B-cell precursor acute lymphoblastic leukemia
(ALL).
Codes
Used in this BI:
J9229 Injection, inotuzumab ozogamicin, 0.1 mg
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Limits
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Intentially left empty
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Reference
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1)
Besponsa Prescribing
Information. Pfizer, Inc. August 2017
2)
Clinical Pharmacology.
Accessed online November 14, 2017.
3)
NCCN Drugs and Biologics
Compendium. Accessed online November 14, 2017.
Addendum:
Effective 05/01/2018:
Updated policy to include new code C9028 for
Besponsa.
Effective 12/01/21: Added
codes to search box. C9028 was
deleted and replaced by J9229 eff 01-01-2021 and added code description in codes
used in this BI.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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