Blinatumomab (Blincyto®)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the medical policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
POLICY
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
A. FDA-Approved Indications
1. Blincyto is indicated for the treatment of CD19-positive B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD) greater than or equal to 0.1% in adults and pediatric patients.
2. Blincyto is indicated for the treatment of relapsed or refractory CD19-positive B-cell precursor acute lymphoblastic leukemia (ALL) in adults and pediatric patients.
B. Compendial Uses
1. Acute lymphoblastic leukemia (ALL)
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review: Testing or analysis confirming CD19 protein on the surface of the B cell
III. CRITERIA FOR INITIAL APPROVAL
B-cell Precursor Acute Lymphoblastic Leukemia
Authorization of 9 months may be granted for treatment of CD19-positive B-cell precursor acute lymphoblastic leukemia (ALL) when one of the following criteria are met:
A. The requested medication will be used as consolidation or maintenance therapy.
B. The requested medication will be used for relapsed or refractory disease.
IV. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in Section III when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
MEDICATION QUANTITY LIMITS
Drug Name |
Diagnosis |
Maximum Dosing Regimen |
Blincyto (Blinatumomab) |
Acute Lymphoblastic Leukemia (ALL): Minimal Residual Disease (MRD) |
Route of Administration: Intravenous ≥45kg 28mcg on days 1-28, followed by 14 days off treatment for up to 4 cycles
<45kg 15mcg/m² (not to exceed 28 mcg/day) on days 1-28, followed by 14 days off treatment for up to 4 cycles |
Blincyto (Blinatumomab) |
Acute Lymphoblastic Leukemia (ALL): Relapsed or Refractory |
Route of Administration: Intravenous ≥45kg 28mcg on days 1-28, followed by 14 or 56 days off treatment for up to 9 cycles
<45kg 15mcg/m² (not to exceed 28 mcg/day) on days 1-28, followed by 14 or 56 days off treatment for up to 9 cycles |
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
ADDITIONAL INFORMATION
For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).
REFERENCES
1. Blincyto [package insert]. Thousand Oaks, CA: Amgen Inc.; June 2023.
2. The NCCN Drugs & Biologics Compendium 2023 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed May 23, 2023.
ORIGINAL EFFECTIVE DATE: 1/22/2015
MOST RECENT REVIEW DATE: 4/9/2024
ID_CHS
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.