Blinatumomab (Blincyto™) is a bispecific CD19-directed CD3 T-cell engager (BiTE) antibody construct product. Blinatumomab (Blincyto) engages the T lymphocytes to destroy leukemia cells. The drug acts as a connector betweenCD19 protein, which is found on the surface of most B-cell lymphoblasts, and CD3 protein, which is found on T-cell lymphocytes. BiTE antibody constructs are modified antibodies that are designed to engage two different targets simultaneously, thereby juxtaposing T cells to cancer cells.
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Blinatumomab (Blincyto) may be considered medically necessary as a single-agent therapy forANYof the following indications:
Food and Drug Administration (FDA) Indications
National Comprehensive Cancer Network (NCCN) Recommendations
The use of blinatumomab (Blincyto) is considered experimental/investigational and, therefore, non-covered for all other indications. Scientific literature does not support the use of blinatumomab (Blincyto) for other indications.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Covered Diagnosis Codes for Procedure Code J9039