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IL-5 inhibitors — Blue Cross Blue Shield of Texas

chronic rhinosinusitis with nasal polyps (CRSwNP)

Initial criteria

  • The patient’s diagnosis was confirmed by anterior rhinoscopy or endoscopy OR computed tomography (CT) of the sinuses
  • ONE of the following: the patient has tried and had an inadequate response to ONE intranasal corticosteroid therapy (e.g., fluticasone nasal spray, mometasone nasal spray, Sinuva) after at least a 4-week duration of therapy OR the patient has an intolerance or hypersensitivity to ONE intranasal corticosteroid therapy (e.g., fluticasone nasal spray, mometasone nasal spray, Sinuva) OR the patient has an FDA labeled contraindication to ALL intranasal corticosteroids
  • If the patient has an FDA labeled indication, then ONE of the following: the patient’s age is within FDA labeling for the requested indication for the requested agent OR there is support for using the requested agent for the patient’s age for the requested indication OR the patient has another indication that is supported in compendia for the requested agent and route of administration
  • If the patient has a diagnosis of severe eosinophilic asthma, then ALL of the following: ONE of the following A) the patient is NOT currently treated with the requested agent AND is currently treated with a maximally tolerated inhaled corticosteroid (ICS) for at least 3 months AND has been adherent for 90 days within the past 120 days OR B) the patient is currently treated with the requested agent AND is treated with an adequately dosed inhaled corticosteroid for at least 3 months with adherence for 90 days within the past 120 days OR C) the patient has an intolerance or hypersensitivity to therapy with an inhaled corticosteroid OR D) the patient has an FDA labeled contraindication to ALL inhaled corticosteroids; AND ONE of the following: currently treated for at least 3 months and adherent for 90 days within past 120 days with one of LABA, LAMA, LTRA, or theophylline OR intolerance or hypersensitivity to LABA/LAMA/LTRA/theophylline OR FDA labeled contraindication to ALL LABA and LAMA; AND the patient will continue asthma control therapy (ICS, ICS/LABA, LTRA, LAMA, theophylline) in combination with the requested agent
  • If diagnosis is hypereosinophilic syndrome (HES), the patient will continue existing HES therapy (e.g., OCS, hydroxyurea, interferon-a, immunosuppressant) in combination with the requested agent
  • If diagnosis is chronic rhinosinusitis with nasal polyps (CRSwNP), BOTH of the following: the patient is currently treated with standard nasal polyp maintenance therapy (e.g., nasal saline irrigation, intranasal corticosteroids [e.g., fluticasone nasal spray, mometasone nasal spray, Sinuva]) AND will continue standard nasal polyp maintenance therapy in combination with the requested agent
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., allergist, immunologist, otolaryngologist, pulmonologist, rheumatologist) or has consulted with a specialist in the area of the patient’s diagnosis
  • ONE of the following regarding concomitant agents: the patient will NOT use the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR, if such combination is used, BOTH of the following: the prescribing information does not limit the use with another immunomodulatory agent AND there is supporting evidence for combination therapy
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient was previously approved for the requested agent through the plan’s prior authorization process
  • ONE of the following applies:
  • For severe eosinophilic asthma: BOTH of the following: 1) The patient has had improvement or stabilization from baseline indicated by one of: increase in FEV1, decreased inhaled corticosteroid dose, decreased systemic corticosteroid need, decreased hospitalizations/urgent visits; AND 2) The patient is currently treated and compliant with asthma control therapy (ICS, ICS/LABA, LTRA, LAMA, theophylline)
  • For EGPA: the patient has had improvement or stabilization as indicated by one of: remission achieved, decreased oral corticosteroid dose, decreased hospitalization, or no increase in corticosteroid or immunosuppressant therapy
  • For HES: BOTH of the following: 1) Improvement or stabilization from baseline indicated by decreased incidence of HES flares OR no escalation in therapy due to worsening clinical symptoms or blood eosinophil counts; AND 2) The patient will continue existing HES therapy (e.g., OCS, hydroxyurea, interferon-a, immunosuppressant) in combination with the requested agent
  • For CRSwNP: BOTH of the following: 1) The patient has had clinical benefit with the requested agent AND 2) The patient will continue standard nasal polyp maintenance therapy (e.g., nasal saline irrigation, intranasal corticosteroids [e.g., fluticasone nasal spray, mometasone nasal spray, Sinuva]) in combination with the requested agent
  • For other indications: The patient has had clinical benefit with the requested agent
  • The prescriber is a specialist in the area of the patient’s diagnosis or has consulted with one
  • ONE of the following regarding concomitant agents: The patient will NOT use the requested agent with another immunomodulatory agent OR, if combination is used, BOTH of the following: The prescribing information does not limit the use with another immunomodulatory agent AND there is support for the use of combination therapy
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months