NUCALA (mepolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. Description: Nucala is a human monoclonal antibody indicated for add-on maintenance in the treatment of severe eosinophilic asthma. It is administered by a healthcare provider. O980.3.docx Page 1 of 7
Definitions: Recurrent Exacerbations: 2 or more acute exacerbations in a 12-month period Severe Asthma: Asthma that does not respond to repeated courses of treatment with beta2-agonist medications. Adult: Age 18 years and older Criteria: See Resources section for FDA-approved dosage. Nucala is considered medically necessary for add-on maintenance treatment of individuals with severe asthma 12 years of age and older, and with an eosinophilic phenotype with documentation of ALL of the following: 1. Nucala is prescribed by an allergist, immunologist, or pulmonologist 2. A blood eosinophil count 1 is equal to or greater than 150 cells/microliter in the past 6 weeks or equal to or greater than 300 cells/microliter in the past 12 months 3. Poor control of severe asthma or recurrent exacerbation requiring additional medication treatment with documentation of ANY of the following: Dyspnea Emergency department (ED) visits Frequent office visits Hospitalizations Limitation of activities of daily living (ADLs) Nighttime awakening Oral corticosteroids 4. Individual is compliant with high-dose inhaled corticosteroids and long acting inhaled beta-2 agonists, and use of oral corticosteroids for exacerbation unless contraindicated. 5. Individuals underlying conditions or triggers for asthma or pulmonary disease are being maximally managed 6. Nucala is not being used concurrently with (Xolair ) 7. Absence of hypersensitivity to mepolizumab or excipients in the formulation O980.3.docx Page 2 of 7
Criteria: (cont.) Nucala for all other indications not previously listed or if above criteria not met is considered experimental or investigational based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives. These indications include, but are not limited to: Acute asthma symptoms Acute bronchospasm Acute exacerbations Allergic bronchopulmonary aspergillosis (ABPA) Atopic dermatitis Chronic obstructive pulmonary disease (COPD) Eosinophilic esophagitis Eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome) Hypereosinophilic syndrome Nasal polyposis Severe allergic asthma (without documentation of severe eosinophilia) Status asthmaticus Treatment with dosing or frequency outside the FDA approved dosing and frequency 1 See conversion tables in Resources section O980.3.docx Page 3 of 7
Resources: Literature reviewed 08/29/17. We do not include marketing materials, poster boards and nonpublished literature in our review. 1. California Technology Assessment Forum "Mepolizumab (Nucala, GlaxoSmithKline) for Asthma." Blue Shield of California Foundation. Nucala Package Insert: - FDA-approved indication and dosage: Indication As add-on maintenance treatment in individuals with severe asthma 12 years and older and with an eosinophilic phenotype Recommended Dose 100 mg subcutaneously every 4 weeks. O980.3.docx Page 4 of 7
Resources: (cont.) Table 1: Conversion of Eosinophil Lab Results to cells/all Results reported in units of K/μL, GI/L, 10 3 cells/μl or 10E3 cells/μl [Note 10 3 = 10E3 the E means exponent] Example Multiply K/μL or GI/L or 10 3 cells/μl or 10E3 cells/μl values by 1000 to get the cells/μl value 0.24 K/μL or GI/L or 10 3 cells/μl or 10E3 cells/μl = 240 cells/μl [0.24 x 1000 = 240] Table 2: Conversion of Eosinophil Lab Results to cells/μl Results reported as Relative % Examples STEP 1: Convert % EOS into a decimal Example #1: % Eosinophil of 1.8% with a reported WBC of 8.5 /μl or % Eosinophil 100 = decimal value GI/L or 10 3 cells/μl or 10E3 cells/μl STEP 2: Convert white blood cell (WBC) count into cells/μl, if not already in these units WBC count in K/μL or GI/L or 10 3 cells/μl 1000 = WBC in cells/μl WBC count in cells/μl use the number given STEP 3: Multiply EOS by WBC count in cells/μl Step 1: 1.8 100 = 0.018 Step 2: 8.5 x 1000 = 8500 cells/μl WBC Step 3: 0.018 x 8500 = 153 cells/μl absolute eosinophil count Example #2: % Eosinophil of 3.9% with a reported WBC of 3846 cells/μl Step 1: 3.9 100 = 0.039 Step 2: No conversion needed, use 3846 cells/μl WBC Step 3: 0.039 x 3846 = 149.994 or 150 cells/μl absolute eosinophil count O980.3.docx Page 5 of 7
Non-Discrimination Statement: Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) 864-4884 for Spanish and (877) 475-4799 for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, (602) 864-2288, TTY/TDD (602) 864-4823, crc@azblue.com. You can file a grievance in person or by mail or email. If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1 800 368 1019, 800 537 7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Multi-Language Interpreter Services: O980.3.docx Page 6 of 7
Multi-Language Interpreter Services: (cont.) O980.3.docx Page 7 of 7