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HealthPartners

Coverage criteria policies

Blinatumomab (Blincyto™)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Blincyto™ requires prior authorization from Pharmacy Administration.

Coverage

Blinatumomab will generally be covered for the treatment of relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) when administered according to the FDA-approved regimen.

The FDA-approved regimens are as follows:

  • A single cycle of treatment consists of 28 days of continuous intravenous infusion followed by a 14-day treatment free interval (total 42 days).
  • For patients greater than or equal to 45 kg, in Cycle 1, administer Blincyto at 9 mcg/day on Days 1-7 and at 28 mcg/day on Days 8-28. For subsequent cycles, administer BLINCYTO at 28 mcg/day on Days 1-28. (2.1)
  • For patients less than 45 kg, in Cycle 1, administer Blincyto at 5 mcg/m²/day on Days 1-7 and at 15 mcg/m²/day on Days 8-28. For subsequent cycles, administer Blincyto at 15 mcg/m²/day on Days 1-28.

Authorizations will be provided for 9 months which should allow for 5 cycles of treatment. Reauthorizations will not be provided.

Definition

Blincyto™ is a bispecific CD19-directed CD3 T-cell engager indicated for the treatment of relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) in adults and children.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Code

Codes

Description

J9039

Injection, blinatumomab, 1 microgram

NDC Codes

Codes

Description

55513016001

35mcg solution

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Blincyto Prescribing Information. Amgen, Inc. Thousand Oaks, CA November 2017.

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Policy activity

  • 02/23/2015 - Date of origin
  • 04/28/2017 - Effective date
Review date
  • 02/2018
Revision date
  • 11/07/2016

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