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    v1.0.28
    OpenPayerPolicy UpdatesHematology/OncologyAloha Care Oncaspar (pegaspargase) Coverage | Open…
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    CurrentAloha CarePolicy RXMP-23

    pegaspargase (Oncaspar) — Medical Benefit Coverage Criteria

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    Medical benefit coverage criteria and authorization requirements for Oncaspar (pegaspargase) for AlohaCare Medicaid and Medicare members, including dosing, contraindications, and billing information.

    Policy Summary
    PayerAloha Care
    Policypegaspargase (Oncaspar)
    Policy CodePolicy RXMP-23
    Change TypeNo material changes
    Effective Date10/20/2025
    Last ReviewMar 31, 2025
    Next Review Date03/31/2025
    Key ActionSubmit prior authorization for Oncaspar (J9266); initial approval is for 3 months with reauthorization up to 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    J9266HCPCS code for Oncaspar
    3 monthsInitial approval
    12 monthsReauthorization
    10/20/2025Effective

    Coverage Criteria for Oncaspar (pegaspargase)

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    General Coverage Criteria

    Covered when ALL of the following are met:

    General Coverage Criteria: 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).

    Pharmacy staff: For QUEST non-ABD members with cancer, send ADRC referral with chart notes through G8 CM module.

    General Coverage Criteria — contraindications: 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.

    This policy assigns coverage for Oncaspar (pegaspargase) to the medical benefit. The medication is excluded from the pharmacy benefit and requires prior authorization when billed under the medical benefit. The covered HCPCS code is J9266, and the policy specifies an initial approval of 3 months with reauthorization of up to 12 months as noted in the formulary status and duration of approval.

    AgeDose (IU/m2)FrequencyCoverage status
    <21 years
    2,500 IU/m2
    Every 14 days (Q14 days)
    Covered per FDA dosing

    Billing and Coding

    Covered HCPCS CodesHCPCSCovered
    J9266Injection pegaspargase per single dose vial; Oncaspar 3750 IU/5mL vial

    Provider Requirements, Authorization, and Risk

    Prior Authorization

    Prior authorization required for Oncaspar (J9266)

    Oncaspar (pegaspargase) (HCPCS J9266) is a medical-benefit drug that requires prior authorization. Initial approvals are for 3 months; continuation/reauthorization may be approved for up to 12 months per policy.

    • Covered HCPCS code: J9266 (Injection pegaspargase per single dose vial).
    • Formulary status: Medical Benefit — Authorization Required.
    • Duration of approval: Initial request: 3 months; COC/Reauthorization: 12 months.
    Step Therapy

    Step therapy policy and 90-day Medicare transition

    Medicare Part B step therapy does not apply for members already on active treatment during the 90-day transition for new Medicare enrollees; for new starts, Medicare Part B Step Therapy Criteria must be met in addition to Coverage Criteria.

    • No step therapy requirement for ongoing treatment during the 90-day Medicare transition period for new Medicare members.
    • For new Medicare Part B starts after the transition, step therapy criteria (if applicable) and coverage criteria must be satisfied before approval.
    Documentation Required

    Required clinical documentation

    Provide chart notes that document the member's eligible diagnosis, prior treatment history, and dosing consistent with FDA recommendations for age (e.g., dosing per FDA: <21 years 2,500 IU/m2 Q14 days; ≥21 years 2,000 IU/m2 Q14 days). For QUEST non-ABD cancer members, include an ADRC referral via the G8 CM module.

    • Documented diagnosis: ALL, ENKL, or Hepatosplenic T‑Cell Lymphoma.
    • Prior treatment history, including any prior L‑asparaginase therapy and related adverse events.
    • Dosing consistent with FDA guidance by age.
    • For QUEST non-ABD members: ADRC referral with chart notes through G8 CM module.
    Denial Risk

    Coverage criteria not met may lead to denial

    Requests that do not meet all elements of the General Coverage Criteria (eligible diagnosis and absence of listed contraindications) may be denied.

    • General Coverage Criteria require: (1) diagnosis of ALL, ENKL, or Hepatosplenic T‑Cell Lymphoma; AND (2) no history of serious thrombosis, pancreatitis, hemorrhagic events with prior L‑asparaginase therapy, or severe hepatic impairment.
    Note

    Medicare transition — meet criteria after 90 days or risk denial

    After the 90-day Medicare transition period for new Medicare members, coverage and any step therapy criteria must be met for continued coverage; failure to meet these criteria may result in denial of coverage or claims.

    • During the first 90 days of enrollment, ongoing active treatment is allowed without applying Coverage or Step Therapy.
    • After 90 days, document compliance with Coverage Criteria (eligible diagnosis and absence of contraindications) and applicable Step Therapy requirements for continued approval.

    Eligible Diagnoses and Contraindications

    Eligible diagnoses
    Eligible diagnoses (NCCN/FDA referenced)Acute lymphoblastic lymphoma or acute lymphocytic (lymphoblastic) leukemia (ALL)
    Eligible diagnoses (NCCN/FDA referenced)Extranodal natural killer T‑cell lymphoma (ENKL) — NCCN category 2A
    Eligible diagnoses (NCCN/FDA referenced)Hepatosplenic T‑Cell Lymphoma — NCCN category 2A
    Contraindications
    ContraindicationHistory of serious thrombosis with prior L‑asparaginase therapy
    ContraindicationHistory of serious pancreatitis with prior L‑asparaginase therapy
    ContraindicationHistory of serious hemorrhagic events with prior L‑asparaginase therapy
    ContraindicationSevere hepatic impairment

    Line of Therapy Considerations

    Line of therapy

    FDA dosing by age: Age <21 years: 2,500 IU/m2 every 14 days; Age ≥21 years: 2,000 IU/m2 every 14 days (per FDA indications).

    Covered Regimens and Dosing

    AgeDose (IU/m2)FrequencyIndication / NotesCoverage status
    <21 years
    2,500 IU/m2
    Every 14 days (Q14 days)
    Acute lymphoblastic leukemia — per FDA dosing
    Covered per FDA dosing

    Background

    Pegaspargase (Oncaspar) is identified in this policy as the product Oncaspar (pegaspargase) supplied as Oncaspar 3750 IU/5 mL vial and billed using HCPCS J9266. The policy references FDA-recognized indications and dosing guidance for use in acute lymphoblastic leukemia and certain lymphomas; dosing and administration details are provided in the FDA product information and the policy’s regimens section. Providers should follow the FDA dosing recommendations by age and supply documentation consistent with those indications when requesting authorization.

    Policy Summary
    PayerAloha Care
    Policypegaspargase (Oncaspar)
    Policy CodePolicy RXMP-23
    Change TypeNo material changes
    Effective Date10/20/2025
    Last ReviewMar 31, 2025
    Next Review Date03/31/2025
    Key ActionSubmit prior authorization for Oncaspar (J9266); initial approval is for 3 months with reauthorization up to 12 months.
    SourceLink
    On This Page
    Coverage Criteria for Oncaspar (pegaspargase)Billing and CodingProvider Requirements, Authorization, and RiskEligible Diagnoses and ContraindicationsLine of Therapy ConsiderationsCovered Regimens and DosingBackground