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Asparaginase Erwinia chrysanthemi (Erwinaze®)

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Erwinaze requires prior authorization from Pharmacy Administration

Coverage

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Asparaginase Erwinia chrysanthem is generally covered when it is used to treat patients meeting all the following criteria:

  • Patients receiving treatment for with acute lymphoblastic leukemia (ALL), and
  • Patients who have developed hypersensitivity to or who are unable to tolerate E. coli-derived asparaginase, either asparaginase (Elspar) or pegylated asparaginase (Oncaspar).

Definitions

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Asparaginase Erwinia chrysanthemi is an asparagine specific enzyme indicated as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia (ALL) who have developed hypersensitivity to E. coli-derived asparaginase.

Codes

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If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Code

J9019 – Injection, asparaginase (Erwinaze)

NDC Codes

57902024901 – 10000 unit solution
57902024905 – 10000 unit solution, multipack

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

References

  1. Erwinaze prescribing information. EUSA Pharma, Inc. November 2011.
  2. Acute Lymphoblastic Leukemia Treatment. National Cancer Institute. 12/15/2011. http://www.cancer.gov/cancertopics/pdq/treatment/childALL/HealthProfessional (Accessed 1/6/2012)
  3. FDA Summary Review. http://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/125359Orig1s000SumR.pdf (Accessed 1/6/2012)
  4. Oncaspar prescribing information. Sigma-tau pharmaceuticals, Inc. May 2011.

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.