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Besponsa (inotuzumab ozogamicin) (Intravenous)

Policy Number: VP-0317

 

Intravenous

 

Last Review Date: 10/30/2023

Date of Origin: 09/19/2017

Dates Reviewed: 09/2017, 11/2018, 11/2019, 11/2020, 11/2021, 11/2022, 11/2023

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization

Coverage will be provided for 6 months (for up to a maximum of 6 cycles) and may NOT be renewed.

  1. Dosing Limits

A. Quantity Limit (max daily dose) [NDC Unit]:

  • Besponsa 0.9 mg powder for injection single-dose vial: 7 vials per 21 days

B. Max Units (per dose and over time) [HCPCS Unit]:

  • 63 billable units every 21 days (for up to a maximum of 6 cycles)
  1. Initial Approval Criteria 1

Coverage is provided in the following conditions:

  • Patient has not previously received treatment with inotuzumab ozogamicin; AND

Universal Criteria 1-3

  • Patient has CD22-positive disease; AND
  • Baseline electrocardiogram (ECG) is within normal limits prior to initiating therapy and will be periodically monitored during treatment; AND

Adult B-Cell Precursor Acute Lymphoblastic Leukemia (ALL) † ‡ Ф 1-3

  • Patient is at least 18 years of age §; AND
    • Patient has relapsed or refractory disease; AND
      • Used as single agent therapy; OR
      • Used in combination with mini-hyper-CVD (cyclophosphamide, dexamethasone, vincristine, methotrexate, cytarabine), with or without blinatumomab as consolidation*; AND
        • Patient is Philadelphia chromosome (Ph)-negative; OR
        • Patient is Philadelphia chromosome (Ph)-positive and refractory to prior tyrosine kinase inhibitor (TKI) therapy (e.g., imatinib, dasatinib, ponatinib, nilotinib, bosutinib, etc.); OR
      • Used in combination with TKI therapy (e.g., bosutinib, dasatinib, imatinib, nilotinib, or ponatinib); AND
        • Patient is Philadelphia chromosome (Ph)-positive; OR
    • Used as frontline therapy; AND
      • Used in combination with mini-hyper-CVD, with or without blinatumomab as consolidation*; AND
      • Patient is Philadelphia chromosome (Ph)-negative

§Adult B-Cell Precursor ALL may be applicable to adolescent and young adult (AYA) patients within the age range of 15-39 years.

*Note: May be used with rituximab for AYA or adults <65 years of age without substantial comorbidities.

Pediatric B-Cell Precursor Acute Lymphoblastic Leukemia (ALL) ‡ 3,4

  • Patient is at least 1 year of age; AND
  • Patient has relapsed or refractory disease; AND
    • Used as single agent therapy; AND
      • Patient is Philadelphia chromosome (Ph)-negative; OR
      • Patient is Philadelphia chromosome (Ph)-positive; AND
        • Patient is intolerant or refractory to prior tyrosine kinase inhibitor (TKI) therapy (e.g., imatinib, dasatinib, etc.); OR
    • Used in combination with mini-hyper-CVD (cyclophosphamide, vincristine, dexamethasone, methotrexate, cytarabine); AND
      • Patient is Philadelphia chromosome (Ph)-negative

FDA Approved Indication(s); Compendium Recommended Indication(s); Ф Orphan Drug

  1. Renewal Criteria 1

Coverage may NOT be renewed.

  1. Dosage/Administration 1

Indication

Dose

B-Cell Precursor ALL

 

Cycle 1:

  • 1.8 mg/m2 total per cycle, administered as 3 divided doses on Day 1 (0.8 mg/m2), Day 8 (0.5 mg/m2), and Day 15 (0.5 mg/m2)
  • Cycle 1 is 3 weeks in duration, but may be extended to 4 weeks if the patient achieves CR or CRi, and/or to allow recovery from toxicity

 

Subsequent Cycles (cycles are 4 weeks in duration):

CR or CRi achieved

  • 1.5 mg/m2 total per cycle, administered as 3 divided doses on Day 1 (0.5 mg/m2), Day 8 (0.5 mg/m2), and Day 15 (0.5 mg/m2)

Did not achieve CR or CRi

  • 1.8 mg/m2 total per cycle, administered as 3 divided doses on Day 1 (0.8 mg/m2), Day 8 (0.5 mg/m2), and Day 15 (0.5 mg/m2)
  • Patients who do not achieve a CR or CRi within 3 cycles should discontinue treatment.

Patients proceeding to HSCT:

  • Recommended duration of treatment is 2 cycles
  • A third cycle may be considered for those patients who do not achieve CR or CRi and MRD negativity after 2 cycles

Patients not proceeding to HSCT:

  • Additional cycles of treatment, up to a maximum of 6 cycles, may be administered

CR (complete remission); CRi (complete remission with incomplete hematologic recovery); HSCT (hematopoietic stem cell transplant); MRD (minimal residual disease)

  • CR is defined as < 5% blasts in the bone marrow and the absence of peripheral blood leukemic blasts, full recovery of peripheral blood counts (platelets ≥ 100 × 109/L and absolute neutrophil counts [ANC] ≥ 1 × 109/L) and resolution of any extramedullary disease.
  • CRi is defined as < 5% blasts in the bone marrow and the absence of peripheral blood leukemic blasts, incomplete recovery of peripheral blood counts (platelets < 100 × 109/L and/or ANC < 1 × 109/L) and resolution of any extramedullary disease.
  1. Billing Code/Availability Information

HCPCS Code:

  • J9229 - Injection, inotuzumab ozogamicin, 0.1 mg; 1 billable unit = 0.1 mg

 

NDC:

  • Besponsa 0.9 mg lyophilized powder in single-dose vial: 00008-0100-xx
  1. References
  1. Besponsa [package insert]. Philadelphia, PA; Pfizer Inc., March 2018. Accessed September 2023.
  2. Kantarjian HM, DeAngelo DJ, Stelljes M, et al. Inotuzumab Ozogamicin versus Standard Therapy for Acute Lymphoblastic Leukemia. N Engl J Med. 2016 Aug 25;375(8):740-53.
  3. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) inotuzumab ozogamicin. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed September 2023.
  4. Bhojwani D, Sposto R, Shah NN, et al. Inotuzumab ozogamicin in pediatric patients with relapsed/refractory acute lymphoblastic leukemia [published correction appears in Leukemia. 2019 Mar 7;:]. Leukemia. 2019;33(4):884–892.
  5. O’Brien MM, Ji L, Shah NN, et al. Phase II trial of inotuzumab ozogamicin in children and adolescents with relapsed or refractory B-cell acute lymphoblastic leukemia: Children’s Oncology Group Protocol AALL1621. J Clin Oncol 2022;40:956-967
  6. Pennesi E, Michels N, Brivio E, et al. Inotuzumab ozogamicin as single agent in pediatric patients with relapsed and refractory acute lymphoblastic leukemia: results from a phase II trial. Leukemia 2022;36:1516-1524
  7. Jabbour EJ, Sasaki K, Ravandi F, et al. Inotuzumab ozogamicin in combination with low-intensity chemotherapy (mini-HCVD) with or without blinatumomab versus intensive chemotherapy (HCVAD) as frontline therapy for older patients with Philadelphia chromosome-negative acute lymphoblastic leukemia: A propensity score analysis. Cancer 2019;125:2579-2586.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

C83.50

Lymphoblastic (diffuse) lymphoma, unspecified site

C83.51

Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck

C83.52

Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes

C83.53

Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes

C83.54

Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb

C83.55

Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb

C83.56

Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes

C83.57

Lymphoblastic (diffuse) lymphoma, spleen

C83.58

Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites

C83.59

Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites

C91.00

Acute lymphoblastic leukemia not having achieved remission

C91.01

Acute lymphoblastic leukemia, in remission

C91.02

Acute lymphoblastic leukemia, in relapse

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs), and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCA/LCD): N/A

 

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

 

BESPONSA® (inotuzumab ozogamicin) Prior Auth Criteria
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