Clinical Policy: (Neulasta) Reference Number: CP.CPA.127 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description (Neulasta ) is a leukocyte growth factor. FDA approved indication Neulasta is indicated to: Decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia. Increase survival in patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Subsyndrome of Acute Radiation Syndrome). Limitation of use: Neulasta is not indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation. Policy/Criteria Provider must submit documentation (which may include office chart notes and lab results) supporting that member has met all approval criteria. It is the policy of health plans affiliated with Centene Corporation that Neulasta is medically necessary when the following criteria are met: I. Initial Approval Criteria A. Chemotherapy-Induced Neutropenia (Primary Prophylaxis) (must meet all): 1. Patient is receiving myelosuppressive chemotherapy; 2. One of the following (a or b): a. Chemotherapy regimen is expected to cause febrile neutropenia; b. Patient is at higher risk for chemotherapy-induced infectious complications including, but not limited to one of the following: i. Pre-existing neutropenia due to disease, extensive prior chemotherapy; ii. Decreased immune function; iii. Previous radiation to areas containing large amounts of bone marrow; iv. Active tissue infection(s); v. Open wound(s); vi. Age greater than 65 years old; 3. Dose does not exceed: 6 mg/dose. Approval duration: Length of benefit Page 1 of 6
B. Chemotherapy-Induced Neutropenia (Secondary Prophylaxis) (must meet all): 1. Patient is receiving myelosuppressive chemotherapy; 2. Patient has a history of febrile neutropenia following a previous course of chemotherapy; 3. Dose does not exceed: 6 mg/dose. Approval duration: Length of benefit C. Radiation Exposure (must meet all): 1. Patient is acutely exposed to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome); 2. Dose does not exceed: 6 mg/dose. Approval duration: 2 doses D. Peripheral Blood Stem Cell (PBSC) Mobilization [off-label] (must meet all): 1. Prescribed to mobilize peripheral blood progenitor cell collection (PBPC) prior to autologous transplantation; 2. Dose does not exceed: 12 mg/dose. Approval duration: Length of benefit E. Other diagnoses/indications 1. Refer to CP.CPA.09 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). II. Continued Therapy A. All Indications (must meet all): 1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; 2. Documentation of positive response to therapy; 3. Dose does not exceed: 6 mg/dose (12 mg/dose for PBSC mobilization). Approval duration: Radiation Exposure - 2 doses Other Indications Length of benefit B. Other diagnoses/indications (must meet 1 or 2): 1. Currently receiving medication via Centene benefit and documentation supports positive response to therapy. Approval duration: Duration of request or 12 months (whichever is less); or 2. Refer to CP.CPA.09 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). III. Diagnoses/Indications for which coverage is NOT authorized: A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policy CP.CPA.09 or evidence of coverage documents. Page 2 of 6
IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key G-CSF: granulocyte-colony stimulating factor PBSC: peripheral blood stem cell Appendix B: General Information The development of febrile neutropenia is a common dose-limiting toxicity of many chemotherapy regimens. This risk is directly related to the intensity of the chemotherapy regimen. Chemotherapy regimens that have an incidence of febrile neutropenia greater than 20% in clinical trials in chemotherapy naïve patients are considered by the NCCN panel at high risk. Prophylaxis with myeloid growth factors is recommended at this level of risk. According to NCCN practice guidelines, in addition to chemotherapy regimens, other risk factors such as: treatment-related, patient-related, cancer-related, and comorbidities have been associated with an increased risk of febrile neutropenia. Therefore, the type of chemotherapy regimen is only one component of the risk assessment. Per NCCN practice guidelines; there are insufficient data to support use of Neulasta with chemotherapy schedules given more frequently than every 2 weeks. There is currently a lack of evidence to support use of Neulasta for treatment of febrile neutropenia. Following myeloablative chemotherapy, Neulasta was effective and safe for mobilizing blood progenitor cells before autologous transplantation in patients with hematological malignancies (class IIa recommendation per Drugdex). ASCO 2006 clinical practice guidelines for the appropriate use of hematopoietic colony stimulating factors (CSF) in patients with cancer recommend the use of CSFs as adjunctive therapy for progenitor cell transplantation. CSFs may be used, often in conjunction with chemotherapy, to mobilize peripheral-blood progenitor cells (PBPC) for leukaphereis collection and to shorten the neutropenic period after cytoreduction and autologous bone marrow transplantation. Post-transplant use of granulocyte-colony stimulating factor (G-CSF, filgrastim) after an autologous PBPC transplant has been found to shorten hospitalization and reduce overall medical costs. Recent evidence supports dose reduction of pegylated interferon according to FDA approved labeling as treatment for neutropenia occurring in hepatitis C patients treated with combination therapy (pegylated interferon + ribavirin). Treatment with Neulasta is not FDA approved or recommended by current hepatitis C treatment guidelines. Appendix C: Therapeutic Alternatives Drug Dosing Regimen Maximum Dose Neupogen (filgrastim) 10 mcg/kg SC QD 24 cg/kg SC QD Therapeutic alternatives are listed as Brand name (generic) when the drug is available by brand name only and generic (Brand name ) when the drug is available by both brand and generic. V. Dosage and Administration Indication Dosing Regimen Maximum Dose Chemotherapy-Induced Neutropenia 6 mg SC one time per chemotherapy cycle 6 mg/dose Page 3 of 6
Radiation Exposure Peripheral Blood Stem Cell (PBSC) Mobilization [off-label] Do not administer within 7 days prior to next administration of cytotoxic chemotherapy and within 24 hours after administration of cytotoxic chemotherapy. 6 mg SC one time, followed by a second dose of 6 mg SC one week later for a total of 2 doses. 6 mg or 12 mg SC one time per transplant. 6 mg/dose 12 mg/transplant VI. Product Availability Injection: 6 mg/0.6 ml solution in a single-dose prefilled syringe Injection: 6 mg/0.6 ml solution in a single-dose prefilled syringe co-packaged with the On-body Injector VII. References 1. Neulasta Prescribing Information. Thousand Oaks, California: Amgen Inc; April 2016. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/125031s184lbl.pdf Accessed January 12, 2017. 2. American Society of Clinical Oncology 2006 Update of Recommendations for the Use of White Blood Cell Growth Factors: An Evidence-Based Clinical Practice Guideline. J Clin Oncology. 2006; 24: 3187-3205. 3. National Comprehensive Cancer Network.Myeloid Growth Factors Version 1.2016. Available at: http://www.nccn.org/professionals/physician_gls/pdf/myeloid_growth.pdf.accessed June8, 2016. 4. Micromedex Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed January 12, 2017. 5. Neulasta. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed January 12, 2017. 6. Neulasta Drug Monograph. Clinical Pharmacology. Accessed January 12, 2017. Reviews, Revisions, and Approvals Date P&T Approval Date Converted to new template. Minor changes to verbiage and grammar. References updated. 01.12.17 11.17 Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical Page 4 of 6
policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. 2016 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or Page 5 of 6
remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 6 of 6