Medical Policy Updates

Notification of Policy Revisions Effective May 12, 2020 Posted March 10, 2020

Medical Policy Revision
Interleukin-5 Antagonists “Notification” Under "When Covered" section, added the following: "For mepolizumab (Nucala) and benralizumab (Fasenra) requests, the patient has a physical or cognitive limitation that makes the utilization of a self-administered formulation unsafe or otherwise not feasible. This must be demonstrated by both of the following: 1. Inability to self-administer the medication; AND 2. Lack of caregiver or support system for assistance with administration of self-administered products." Added the following continuation criteria for Nucala for eosinophilic granulomatosis with polyangiitis (EGPA/Churg-Strauss Syndrome): "when the patient is stable on oral corticosteroids (OCS)." Medical Director review 3/2020. Notification given 3/10/2020 for effective date 5/12/2020.