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.
Blincyto™ requires prior authorization from Pharmacy Administration.
Blinatumomab will generally be covered for the treatment of Philadelphia chromosome-negative (Ph-) 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.
Blincyto™ is a bispecific CD19-directed CD3 T-cell engager indicated for the treatment of Philadelphia chromosome-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL). This indication is approved under accelerated approval. Continued approval for this medication may be contingent upon verification of clinical benefit in subsequent trials.
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.
Injection, blinatumomab, 1 microgram
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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.
- American Cancer Society. Leukemia--Acute Lymphocytic Detailed Guide. Available at: http://www.cancer.org/cancer/leukemia-acutelymphocyticallinadults/detailedguide/index [Accessed December 15, 2014]
- Amgen. Blincyto [Prescribing Information]. September 2016. Thousand Oaks, CA Available at: http://pi.amgen.com/united_states/blincyto/blincyto_pi_hcp_english.pdf [Accessed December 15, 2014]
- National Cancer Institute. Adult Acute Lymphoblastic Leukemia Treatment http://www.cancer.gov/cancertopics/pdq/treatment/adultALL/HealthProfessional#_14_toc [Accessed December 15, 2014]
- NCCN Clinical Practice Guidelines in Oncology. Acute-Lymphoblastic Leukemia. Version 1.2014
- Available at: http://www.nccn.org/professionals/physician_gls/pdf/all.pdf Treatment of relapsed or refractory chronic lymphocytic leukemia. [Accessed December 15, 2014]