CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oncaspar (pegaspargase) — Coverage Criteria

Defines coverage and authorization criteria for Oncaspar (pegaspargase) for Neighborhood Health Plan of Rhode Island members when used for FDA-approved indications and selected compendial uses, including treatment and continuation of therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOncaspar (pegaspargase) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required; authorization of up to 12 months may be granted for listed indications and for continuation when no unacceptable toxicity or disease progression is present.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration granted for approved indications and continuation

FDA-approved + compendialindications considered covered when criteria met

multiplecancer types listed

Coverage and Medical Necessity Criteria

Covered indications and authorization

General coverage requirement: Indication is an FDA-approved indication or a compendial use listed in the policy and the member has no exclusions to the prescribed therapy.

Supports initial authorization

Indications considered covered: Acute lymphoblastic leukemia (ALL) as a component of multi-agent chemotherapy (including pediatric and adult patients) and for patients with hypersensitivity to native L-asparaginase; Lymphoblastic lymphoma (managed same as ALL); Extranodal natural killer/T-cell lymphoma, nasal type as a component of multi-agent chemotherapy; Hepatosplenic T-cell lymphoma as subsequent therapy if no response or progressive disease after first‑line therapy; Pediatric acute lymphoblastic leukemia as a component of multi-agent chemotherapy.

List derived from FDA-approved indications and compendial uses

Authorization duration: Requested medication is used in conjunction with multi-agent chemotherapy or as central nervous system–directed systemic therapy; authorization may be granted for 12 months.12 months

Applies to initial authorization

Continuation/Reauthorization: Reauthorization for continued treatment may be granted for 12 months when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.12 months

Continuation criteria

All other indications are considered experimental/investigational and not medically necessary. This policy limits coverage to the FDA-approved indications and the compendial uses explicitly listed for Oncaspar (pegaspargase); treatments outside those indications will be denied as not covered.

Use of Oncaspar (pegaspargase) for indications that are not among the FDA-approved indications or the compendial uses listed in this policy is considered not medically necessary. Providers should request prior authorization only for the covered indications; requests for off‑label uses not listed in the compendia will not meet medical necessity criteria.

Regimen / Indication	Coverage status	Authorization duration / Notes
Oncaspar (pegaspargase) as a component of a multi-agent chemotherapeutic regimen for acute lymphoblastic leukemia (ALL)	Covered	Authorization of up to 12 months may be granted when used in conjunction with multi-agent chemotherapy or as CNS-directed systemic therapy
Oncaspar for ALL with hypersensitivity to native L-asparaginase (component of multi-agent chemotherapy)	Covered	Authorization of up to 12 months may be granted when used in conjunction with multi-agent chemotherapy
Oncaspar as component of multi-agent chemotherapy for lymphoblastic lymphoma (managed same as ALL)	Covered	Authorization of up to 12 months may be granted when used in conjunction with multi-agent chemotherapy or as CNS-directed systemic therapy
Oncaspar as component of multi-agent chemotherapy for extranodal natural killer/T-cell lymphoma, nasal type	Covered	Authorization of up to 12 months may be granted when used in conjunction with multi-agent chemotherapy
Oncaspar as subsequent therapy (post–first-line) for hepatosplenic T‑cell lymphoma when no response or progressive disease after first‑line therapy (component of multi‑agent chemotherapy)	Covered	Authorization of up to 12 months may be granted when used in conjunction with multi-agent chemotherapy
Oncaspar for pediatric acute lymphoblastic leukemia (component of multi-agent chemotherapy)	Covered	Authorization of up to 12 months may be granted when used in conjunction with multi-agent chemotherapy

Coding and Authorization Duration

Referenced materials (no codes listed)mixed

No codes listed

Authorization duration

Authorization durationAuthorization of 12 months may be granted when Oncaspar is used in conjunction with multi‑agent chemotherapy or as CNS‑directed systemic therapy.

Reauthorization/ContinuationReauthorization for continued treatment may be granted for 12 months if there is no evidence of unacceptable toxicity or disease progression on the current regimen.

Applies to listed indications12‑month authorization applies to covered indications such as ALL, LL, extranodal NK/T‑cell lymphoma (nasal type), and hepatosplenic T‑cell lymphoma when used per policy criteria.

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for ONCASPAR (pegaspargase). Authorization of up to 12 months may be granted for listed indications and for continuation when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Authorization duration: up to 12 months for treatment when used with multi-agent chemotherapy or as CNS-directed systemic therapy.
Reauthorization: may be granted for 12 months for continuation when no unacceptable toxicity or disease progression is present.

Denial Risk

Non‑covered Indications

Providers must request authorization for indications that are FDA-approved or supported by compendia. Use for indications not listed (i.e., not FDA-approved or compendial uses) is considered experimental/investigational and is not medically necessary.

Non-covered indications: all indications not enumerated in the compendial list (e.g., any use outside acute lymphoblastic leukemia, lymphoblastic lymphoma, extranodal NK/T‑cell lymphoma nasal type, hepatosplenic T‑cell lymphoma as specified, and pediatric ALL as component of multi-agent regimens).

Note

Authorization Duration and Reauthorization

Provider action: Authorization may be granted for 12 months for the treatment of acute lymphoblastic leukemia (ALL) or lymphoblastic lymphoma (LL) when the requested medication is used in conjunction with multi‑agent chemotherapy or as central nervous system directed systemic therapy. Authorization of 12 months may also be granted for treatment of extranodal natural killer/T‑cell lymphoma, nasal type when used with multi‑agent chemotherapy.

Compendial uses include: lymphoblastic lymphoma (managed as ALL); extranodal NK/T‑cell lymphoma, nasal type (as component of multi‑agent chemotherapy); acute lymphoblastic leukemia (ALL) as component of multi‑agent chemotherapy or CNS‑directed systemic therapy; hepatosplenic T‑cell lymphoma as additional therapy after first‑line failure; pediatric ALL as component of multi‑agent chemotherapy.
Continued treatment reauthorization requires no evidence of unacceptable toxicity or disease progression.

Background and Drug Information

Oncaspar (pegaspargase) is used as part of multi‑agent chemotherapy regimens for acute lymphoblastic leukemia (ALL) and related lymphoid malignancies and may be used as central nervous system‑directed systemic therapy. The compendial uses include: lymphoblastic lymphoma (managed the same as ALL), extranodal natural killer/T‑cell lymphoma, nasal type as a component of multi‑agent chemotherapy, hepatosplenic T‑cell lymphoma as subsequent therapy if there is no response or disease progression after first‑line therapy, and pediatric ALL as part of multi‑agent regimens. Coverage is limited to these FDA‑approved and compendial indications when all policy criteria are met.

Definitions

Oncaspar (pegaspargase)

Drug name (generic)Pegaspargase

Brand nameOncaspar

DescriptionA pegylated form of L‑asparaginase used as a component of multi‑agent chemotherapy for pediatric and adult acute lymphoblastic leukemia (ALL) and for patients with hypersensitivity to native L‑asparaginase.

ReferencePolicy reference number 2291‑A

Line of Therapy / Salvage

salvage

Hepatosplenic T-cell lymphoma use: Authorization of 12 months may be granted as subsequent (salvage) therapy when used in conjunction with multi-agent chemotherapy.12 months

Indicates use as subsequent (post first‑line) therapy