Medicare AdvantagePrior AuthHigh impact
Blincyto® (blinatumomab) (Revised)
Humana·KY, SC · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Jan 1, 2020
We identified it
Aug 12, 2026
Summary
This is a revised Blincyto (blinatumomab) pharmacy coverage policy effective January 1, 2020, with the most recent revision dated July 22, 2026. The policy establishes prior authorization requirements for Blincyto use across four indications: relapsed/refractory B-cell ALL (Ph-negative and Ph-positive), B-cell precursor ALL with MRD, and B-cell precursor ALL in consolidation phase. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) with specific clinical criteria that must be met for approval.
Action Required
By July 22, 2026 (effective date of latest revision): Billing and clinical teams must ensure all Blincyto (blinatumomab) claims for Medicare Advantage, Traditional Medicare, and Medicaid (KY, SC) members require prior authorization before submission. Verify the following criteria are documented before requesting PA: (1) For relapsed/refractory B-cell ALL: confirm Philadelphia chromosome status and whether used as monotherapy or with tyrosine kinase inhibitors (bosutinib, dasatinib, imatinib, nilotinib, ponatinib); (2) For MRD-positive B-cell precursor ALL: confirm patient is in first or second complete remission with MRD ≥0.1%; (3) For consolidation phase: confirm use within multiphase chemotherapy protocol. Update billing system to flag all J9313 claims for these states and plans for prior auth requirement. Failure to obtain PA will result in claim denials. Train providers to document remission status, MRD levels, and treatment phase in clinical notes to support PA requests.