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.
Inotuzumab ozogamicin (Besponsa) may be considered medically necessary for the treatment of individuals (18 years of age or older) when used as single agent therapy for EITHERof the following indications:
- For relapsed/refractory Philadelphia chromosome-positive B-ALL in tyroskine-kinase inhibitor (TKI) intolerant/refractory individuals; or
- For relapsed/refractory Philadelphia chromosome-negative B-ALL.
Inotuzumab ozogamicin (Besponsa) for any other indication is considered experimental/investigational, as scientific evidence does not support the use of inotuzumab ozogamicin (Besponsa) for any other indication.