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Coverage criteria policies

Asparaginase Erwinia chrysanthemi (Erwinaze®)

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

Erwinaze requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Asparaginase Erwinia chrysanthem is generally covered when it is used to treat patients meeting all the following criteria:

  • Patients receiving treatment for acute lymphoblastic leukemia (ALL), and
  • Patients who have developed hypersensitivity to or who are unable to tolerate pegylated asparaginase (Oncaspar).

Initial approvals will be provided for six months. Renewals will be provided annually with documentation that the medication is effective.

Definitions

Asparaginase Erwinia chrysanthemi is an asparagine specific enzyme indicated as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia (ALL) who have developed hypersensitivity to E. coli-derived asparaginase.

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

J9019

Injection, asparaginase (Erwinaze), 1,000 IU

NDC Codes

Codes

Description

57902024901

Erwinaze 10000 UNIT SOLR

57902024905

Erwinaze 10000 UNIT SOLR

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. Erwinaze prescribing information. Jazz Pharmaceuticals, Palo Alto, CA 94304. March 2016.

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Policy activity

  • 02/05/2018 - Date of origin
  • 04/01/2018 - Effective date

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