Coverage Policies

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Current policies effective through April 30, 2024.

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QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 01/01/2018	Title: Besponsa
Revision Date: 05/01/2018	Document: BI562:00
CPT Code(s): C9028, J9229
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) 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.
Medical Statement
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
Reference
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.
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.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.