IL-5 inhibitors — Blue Cross Blue Shield of Illinois

Initial criteria

• Diagnosis confirmed by anterior rhinoscopy or endoscopy OR computed tomography (CT) of the sinuses
• Patient has tried and had inadequate response to ONE intranasal corticosteroid therapy (e.g., fluticasone nasal spray, mometasone nasal spray, Sinuva) after ≥ 4 weeks OR has intolerance/hypersensitivity or FDA labeled contraindication to all intranasal corticosteroids
• If patient has severe eosinophilic asthma: must meet ALL of the following: (A) one of: (1) not currently treated with requested agent and treated with a maximally tolerated inhaled corticosteroid (ICS) for ≥3 months and adherent 90 of past 120 days OR (2) currently treated with requested agent and: currently treated with adequately dosed ICS for ≥3 months and adherent 90 of past 120 days OR treated with maximally tolerated ICS for ≥3 months and adherent 90 of past 120 days OR has intolerance/hypersensitivity or FDA contraindication to all ICS; AND (B) one of: currently treated and adherent for ≥90 of past 120 days with ONE LABA, LAMA, LTRA, or theophylline OR has intolerance/hypersensitivity or FDA contraindication to all these; AND (C) will continue asthma control therapy (ICS, ICS/LABA, LTRA, LAMA, theophylline) with requested agent
• If patient has HES: will continue existing HES therapy (e.g., OCS, hydroxyurea, interferon-a, immunosuppressant) with requested agent
• If patient has CRSwNP: BOTH (A) currently treated with standard nasal polyp maintenance therapy (nasal saline irrigation, intranasal corticosteroids) AND (B) will continue such maintenance therapy with requested agent
• Prescriber is a specialist in allergy, immunology, otolaryngology, pulmonology, or rheumatology, or has consulted with one
• Not using requested agent with another immunomodulatory agent (e.g., TNF inhibitor, JAK inhibitor, IL-4 inhibitor) OR combination is supported and PI does not limit use
• Patient does not have any FDA labeled contraindications to requested agent
• If applicable, criteria for Ohio plan: member resides in Ohio AND plan is Fully Insured or HIM Shop AND (no FDA contraindications) AND (has FDA labeled indication or compendia-supported indication or two peer-reviewed clinical trial articles supporting use)

Reauthorization criteria

• Patient previously approved via prior authorization
• For severe eosinophilic asthma: patient had improvement or stabilization with requested agent per one of: increased FEV1, decreased ICS dose, decreased systemic corticosteroid need, or fewer exacerbations/hospitalizations; AND is compliant with asthma control therapy within past 90 days
• For EGPA: has improvement or stabilization with one of: remission achieved, decreased oral corticosteroid dose, fewer hospitalizations, or maintenance corticosteroid/immunosuppressant dose not increased
• For HES: has improvement or stabilization such as decreased HES flares or no escalation of therapy, AND will continue existing HES therapy with requested agent
• For CRSwNP: has clinical benefit AND will continue standard nasal polyp maintenance therapy with requested agent
• For other indications: has clinical benefit with requested agent
• Prescriber is a specialist (or consulted specialist) and agent not used in prohibited combination
• Patient has no FDA labeled contraindications to requested agent

Approval duration

12 months (BCBSIL and BCBSTX); other plans: initial 6 months for severe eosinophilic asthma and CRSwNP, 12 months for EGPA, HES, other; renewal 12 months