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Coverage criteria policies

Inotuzumab ozogamicin (Besponsa™) – Minnesota Health Care Programs

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

Inotuzumab ozogamicin (Besponsa) requires prior authorization from HealthPartners Pharmacy Administration.


Besponsa is generally covered subject to the indications listed below when all of the following criteria are met, and per your plan documents.

Initial Authorizations

  1. Patient must be 18 years of age or older; and,
  2. Patient has relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL); and,
    1. Patient is Philadelphia chromosome (Ph)-negative; or,
    2. Patient is Philadelphia chromosome (Ph)-positive and failed previous therapy with a tyrosine kinase inhibitor (e.g., imatinib, dasatinib, ponatinib, etc.); and,
  3. Patient has not previously received inotuzumab ozogamicin; and,
  4. Has baseline electrocardiogram (ECG) within normal limits; and,
  5. Prescriber attests that patient will be monitored closely for signs and symptoms of Hepatic Veno-occlusive Disease (VOD) (Sinusoidal Obstruction Syndrome) or other severe liver toxicity; and,
  6. Besponsa will be used as single agent therapy.

Initial approval is for three months.


  1. Patient must not have unacceptable toxicity from the drug; and,
  2. Not have documented antibodies to inotuzumab ozogamicin; and,
  3. Has complete remission (CR) or complete remission with incomplete hematologic recovery (Cri) and not proceeding to post-hematopoietic stem cell transplant (HSCT); and,
  4. Not have low absolute neutrophil count (ANC) or low platelet count persisting for greater than 28 days suspected to be related to Besponsa.

Reauthorization is for three months.


1.8 mg/m2/cycle; maximum of 6 cycles.

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.

The services associated with these codes require prior authorization:
HCPC Codes




Injection, inotuzumab ozogamicin, 0.1 mg

NDC Codes




Besponsa 0.9 MG SOLR

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.



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Policy activity

  • 05/07/2018 - Date of origin
  • 10/01/2018 - Effective date
Review date
  • 05/2019

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