Update to Age Requirement for Prior Authorization of Inotuzumab Ozogamicin (Besponsa)

Date: June 6, 2024

Attention: All Providers

Effective for dates of service on or after: July 1, 2024

Call to action: The purpose of this communication is to inform providers that effective for dates of service on or after July 1, 2024, the age requirement for prior authorization of inotuzumab ozogamicin (Besponsa) (procedure code J9229) will be expanded to include pediatric and adult clients who are one year of age or older.

How this impacts providers: Providers should reference the current Texas Medicaid Provider Procedures Manual (TMPPM)Outpatient Drug Services Handbook, subsection 6.67.1, “Prior Authorization Requirements for Inotuzumab ozogamicin (Besponsa)”, for additional prior authorization criteria. Some of the criteria are as follows.

• Client has a confirmed diagnosis of precursor B-cell acute lymphoblastic leukemia (ALL) that is refractory or in relapse
• The prescriber must agree to monitor the client for signs and symptoms of hepatic veno-occlusive disease (VOD) for the duration of Besponsa therapy. Refer to: Subsection 2.1.2, “Prior Authorization Requests” in the TMPPM for additional prior authorization information.
• All services are subject to retrospective review to ensure that the documentation in the patient’s medical record supports the medical necessity of the service(s) provided.
• Besponsa is not a benefit for patients who have hepatic veno-occlusive disease.

For additional guidance, please reference: Subsection 2.1.2, “Prior Authorization Requests” in the TMPPM.

Next step for Providers: Providers are strongly encouraged to follow the guidance as specified from the resources mentioned above. Prescribers should share this communication with their staff.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.