RXMP-23 Pegaspargase (Oncaspar) Form

Page 1 of 2

AlohaCare Medical Policy pegaspargase (Oncaspar)

Policy Number:
RXMP-23 Current Effective Date:
10/20/2025 Original Effective Date:
10/1/2023 (Medicaid), 1/1/2024 (Medicare) Next Review/Revision Date:
3/31/2025 Plans:
AlohaCare Medicaid & Medicare

PRODUCT(S): Oncaspar (pegaspargase)

HCPCS Code HCPCS Description How Supplied J9266 Injection pegaspargase per single dose vial Oncaspar 3750 IU/5mL vial

Formulary Status: Medical Benefit: Authorization Required
Pharmacy Benefit: Excluded to Medical Benefit
Duration of Approval: Initial Request: 3 months COC/Reauthorization: 12 months
Quantity Limit: See dosing information

MEDICARE PART B COVERAGE CRITERIA: • Review using the most current Local Coverage Determination (LCD), National Coverage Determination (NCD), or Local Coverage Article (LCA) that applies to the Hawaii region. The LCD, NCD, or LCA can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. • No LCD/NCD/LCA found as of 9/12/2023. Review using General Coverage Criteria below.

MEDICARE PART B 90-DAY TRANSITION PERIOD:
For new Medicare members, a 90-day transition period applies. During this time, if a member is currently on an active course of the requested treatment, including when furnished by an out-of- network provider, Coverage and Step Therapy do not apply. After the first 90 days of enrollment, Coverage and Step Therapy Criteria must be met for continued coverage.

MEDICARE PART B STEP THERAPY CRITERIA: • For new starts, Medicare Part B Step Therapy Criteria must be met in addition to Coverage Criteria before a request may be approved.
• No step therapy

GENERAL COVERAGE CRITERIA:  Pharmacy staff: For QUEST non-ABD members with cancer, send ADRC (Aid to Disability Referral Committee) referral with chart notes through G8 CM module.

1. Member has a diagnosis of one of the following:
   a. Acute lymphoblastic lymphoma or acute lymphocytic (lymphoblastic) leukemia (ALL) b. Extranodal natural killer T-cell lymphoma (ENKL) (NCCN 2A) c. Hepatosplenic T-Cell Lymphoma (NCCN 2A) AND
2. Member does not have any of the following contraindications: a. History of serious thrombosis with prior L-asparaginase therapy b. History of serious pancreatitis with prior L-asparaginase therapy
   c. History of serious hemorrhagic events with prior L-asparaginase therapy d. Severe hepatic impairment

Page 2 of 2

FDA INDICATIONS, DOSING & ADMINISTRATION: Indication Dosing/Administration Acute Lymphoblastic Leukemia (ALL) Age under 21 years: 2,500 IU/m2 Q14 days Age ≥21 years: 2,000 IU/m2 Q14 days

REFERENCES:

1. DailyMed. Package inserts. U.S. National Library of Medicine, National Institutes of Health website. http://dailymed.nlm.nih.gov/dailymed/about.cfm. Accessed: September 19, 2023.

2. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology, Plymouth Meeting, PA: NCCN. http://www.nccn.org/index.asp. a. Acute Lymphoblastic Leukemia. V1.2022. Revised April 4, 2022.
   b. Pediatric Acute Lymphoblastic Leukemia. V1.2023. Revised November 9, 2022.
   c. Acute Lymphoblastic Leukemia. V2.2022. Revised March 7, 2022.

   CHANGE HISTORY: 9/12/2023 PH: New