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Date Printed: October 23, 2017: 02:17 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-J0000-38

Original Effective Date: 04/15/01

Reviewed: 09/13/17

Revised: 10/15/17

Subject: Etanercept (Enbrel®)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Dosage/ Administration Billing/Coding Reimbursement Program Exceptions Definitions
           
Related Guidelines Other References Updates  
           

DESCRIPTION:

Etanercept (Enbrel) is one of five commercially available tumor necrosis factor (TNF)-alpha inhibitors, not counting biosimilars as separate products, available in the United States, and was first approved in November 1998. Tumor necrosis factor, a proinflammatory cytokine, initiates the body’s defense response to local injury by stimulating the production of inflammatory mediators and signaling immune cells. TNF may augment host defense mechanisms when in low concentration, but large amounts of TNF can lead to excessive inflammation and tissue deterioration. In rheumatoid arthritis, activated T-cells migrate into the synovial lining of the joint where TNF is released and joint destruction begins. The intestinal mucosa from patients with Crohn’s disease or ulcerative colitis has been associated with high levels of TNF as compared to healthy individuals; a similar elevation in TNF has been demonstrated in patients with psoriasis.

Biological agents exhibiting antagonistic properties for TNF bind to the cytokine with a high affinity and prevent TNF binding to receptors on immune, inflammatory, and endothelial cells. TNF-inhibitors may exert action using a variety of biologic activities that may be agent-specific or synergistic with other immunosuppressive agents. Interestingly, many individuals initially non-responsive or intolerant of one TNF-inhibitor have responded when switched to a different agent within the class. Research in this area is imperative in understanding and identifying potential risks and adverse effects associated with use. Combined data from randomized, controlled trials and safety registries have raised concerns that TNF-inhibitors increase the risk of infections and malignancies; although, some studies have found no increased risk as compared to the frequency of infections and malignancies observed in a population predisposed to an immune-mediated inflammatory disease.

Etanercept is approved by the US Food and Drug Administration (FDA) for the treatment of the following conditions: ankylosing spondylitis (2003), polyarticular juvenile rheumatoid arthritis (1999), psoriatic arthritis (2002), chronic plaque psoriasis (2004), and rheumatoid arthritis (1998). In November 2016 the chronic moderate to severe plaque psoriasis indication was expanded to include pediatric patients as young as 4 years of age. At the time of approval, etancercept is the only FDA-approved systemic therapy for pediatric psoriasis. In August 2016 the first biosimilar to etanercept, etanercept-szzs (Erelzi), was FDA approved. As of September 2017, the product has not yet launched. The TNF-alpha inhibitors as a class are considered to have similar efficacy and safety for the majority of indications. Similar to other TNF-alpha inhibitors, the package labeling contains a Boxed Warning regarding potential increased risk of serious infections (e.g., tuberculosis) and certain malignancies during therapy.

In 2015, the American College of Rheumatology (ACR) published an updated guideline for the treatment of rheumatoid arthritis (RA). The guidelines support the use of a TNFi (e.g., etanercept) in the following scenarios: (1) patients with early RA if disease activity remains moderate or high despite DMARD monotherapy (with or without glucocorticoids), use combination DMARDs or a TNFi or a non-TNF biologic (all choices with or without methotrexate (MTX), in no particular order of preference); (2) patients with early RA if disease activity remains moderate or high despite DMARDs, use a TNFi over tofacitinib, (3) patients with established RA if disease activity remains moderate or high despite DMARD monotherapy, use combination traditional DMARDS or add a TNFi or a non-TNF biologic or tofacitinib (all choices with or without MTX, in no particular order of preference); and (4) patients with established RA if disease activity remains moderate or high despite TNFi therapy in patients who are currently not on DMARDs, add one or two DMARDs to TNFI therapy rather than continuation TNFi therapy alone. The avoidance of TNFi therapy and use of alternatives is recommended in certain high-risk conditions([i.e., congestive heart failure, hepatitis C infection and not receiving or requiring antiviral treatment, lymphoproliferative disorders, previously treated or untreated skin cancer, and previous serious infection).

In the 2015 TACIT pragmatic, non-inferiority, randomized controlled trial, 205 persons with established moderate to severe RA received either an anti-TNF biologic with one DMARD (e.g., methotrexate), or conventional DMARD therapy titrated upward to include combination therapy. Most persons in the DMARD group eventually received 2 or 3 DMARDs in combination (e.g., methotrexate + leflunomide). The DMARD group was shown to be non-inferior to the anti-TNF group for the primary outcome of disability measured by a patient-recorded health assessment questionnaire at 12 months with a numerical advantage towards the DMARD group. Further supporting use of combination DMARD therapy, the 2-year follow-up of the SWEFOT trial (438 persons with methotrexate-refractory RA) showed no difference in utility or QALY gain over 21 months when comparing methotrexate + infliximab vs. methotrexate + sulfasalazine + hydroxychloroquine.

While methotrexate must be avoided in women who are pregnant or trying to become pregnant, sulfasalazine has adequate data supporting safe use (pregnancy Category B), and is consider a preferred DMARD if given with folic acid when treatment is clinically necessary. Hydroxychloroquine, cyclosporine, and anti-TNF biologics are also considered to be low-risk options during pregnancy

POSITION STATEMENT:

Comparative Effectiveness

The Food and Drug Administration has deemed the drug(s) or biological product(s) in this coverage policy to be appropriate for self-administration or administration by a caregiver (i.e., not a healthcare professional). Therefore, coverage (i.e., administration) in a provider-administered setting such as an outpatient hospital, ambulatory surgical suite, physician office, or emergency facility is not considered medically necessary.

NOTE: Adalimumab (Humira), etanercept (Enbrel), golimumab (Simponi), and ustekinumab (Stelara) are the preferred self-administered biologic products.

NOTE: If the member has had an inadequate response to previous biologic therapy, other than etanercept, that is FDA-approved for the requested indication listed in Table 1, the member is not required to have had an inadequate response to non-biologic prerequisite therapy (e.g., for RA, if member has previously had an inadequate response to adalimumab but does not have a history of inadequate response to combination csDMARD, they do not have to try two csDMARDs in combination to meet medical necessity criteria).

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Etanercept (Enbrel®) - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Etanercept (Enbrel), adalimumab (Humira), golimumab (Simponi), abatacept (Orencia), and ustekinumab (Stelara) are preferred self-administered products.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Initiation of etanercept (Enbrel) meets the definition of medical necessity when BOTH of the following are met (“1” and “2”):

1. Etanercept is administered for an indication listed in Table 1, and ALL of the indication-specific and maximum-allowable dose criteria are met

2. Etanercept is NOT used in combination with ANY of the following:

a. abatacept (Orencia)

b. adalimumab (Humira)

c. anakinra (Kineret)

d. apremilast (Otezla)

e. brodalumab (Siliq)

f. certolizumab (Cimzia)

g. golimumab (Simponi, Simponi Aria)

h. guselkumab (Tremfya)

i. ixekizumab (Taltz)

j. infliximab products (Remicade, Inflectra, Renflexis)

k. sarilumab (Kevzara)

l. secukinumab (Cosentyx)

m. tocilizumab (Actemra)

n. tofacitinib (Xeljanz, Xeljanz XR)

o. ustekinumab (Stelara)

p. vedolizumab (Entyvio)

Table 1

Indications and Condition Specific Criteria

Indication

Specific Criteria

Maximum Allowable Dose

Axial spondyloarthritis (axSpA)

[including both ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA)]

When BOTH of the following are met (“1” and “2”):

1. Member has a diagnosis of axial spondyloarthritis per ASAS criteria

2. Member has had an inadequate response to, or has a contraindication to at least TWO different NSAID therapies taken continuously for at least 4 weeks each* (e.g., celecoxib, diclofenac, ibuprofen, meloxicam, naproxen) (the specific contraindications must be provided)

50 mg once weekly

Graft-versus-host disease (GVHD)

When BOTH of the following are met (“1and “2”):

1. Member is diagnosed with acute GVHD following an allogenic hematopoietic stem cell (bone marrow) transplant

2. Member’s disease is refractory to an adequate trial of combination therapy with a systemic corticosteroid AND a calcineurin inhibitor (i.e., cyclosporine or tacrolimus). Corticosteroid monotherapy is acceptable for members who have an intolerance or contraindication to a calcineurin inhibitor (the specific intolerance or contraindication must be provided).

0.4 mg/kg (max of 25 mg) twice weekly

Hidradenitis suppurativa (HS) (a.k.a., acne inversa)

*Smoking cessation is highly encouraged in members who smoke. Smoking may worsen the disease and make the disease more refractory to treatment

When ALL of the following are met (“1”, “2”, and “3”):

1. The initiation of etanercept treatment is prescribed by a dermatologist, infectious disease specialist, or surgeon

2. Member has previously had an inadequate response to at least 60 consecutive days of therapy or has contraindications to oral clindamycin (or minocycline) in combination with oral rifampin. For members with a contraindication, persistent intolerable adverse effects, or unavoidable severe drug interactions with the use of rifampin, a trial of at least one oral anti-infective therapy is needed* (failure of ANY or contraindications to ALL of the following):

a. clindamycin

b. dapsone

c. doxycycline

d. minocycline

3. Member’s HS is or was determined to be moderate to severe (must meet BOTH of the following – “a” and “b”):

a. At least ONE of the following:

• Ten or more inflammatory nodules

• Diffuse or near-diffuse inflammatory involvement that precludes quantification of individual nodules

• Two or more abscesses or draining fistulas

• Five or more inflammatory nodules AND at least one abscess or draining fistula

b. EITHER of the following:

• The inflammatory lesions reoccur three or more times during a continuous 6-month time period

• There is persistent involvement of inflammatory lesions for at least 3 months

25 mg twice weekly

Plaque psoriasis (adult)

When ALL of the following are met (“1”, “2”, and “3”):

1. Member is 18 years of age or older

2. Member’s disease is moderate to severe as evidenced by EITHER of the following before or after systemic drug therapy (“a” or “b”):

a. Psoriasis covers 10% or more of member’s BSA

b. Psoriasis covers less than 10% of member’s BSA but affects crucial body areas necessary for daily living activities (i.e., face, palms of hands, soles of feet, or genitals)

3. EITHER of the following* (“a” or “b”):

a. Member has had an inadequate response to at least 3 months of continuous treatment with methotrexate or has a contraindication to methotrexate

b. If methotrexate is contraindicated, the member has had an inadequate response to at least 3 months of continuous treatment with EITHER cyclosporine or acitretin, or has a contraindication to BOTH cyclosporine and acitretin (the specific contraindications must be provided; pregnancy is not considered a contraindication to the use of cyclosporine)

• First 3 months: 50 mg twice weekly

• Maintenance: 50 mg once weekly

Plaque psoriasis (pediatric)

When ALL of the following are met (“1”, “2”, and “3”):

1. Member is 4 to 17 years of age

2. Member’s disease is moderate to severe as evidenced by EITHER of the following before or after systemic drug therapy (“a” or “b”):

a. Psoriasis covers 10% or more of member’s BSA

b. Psoriasis covers less than 10% of member’s BSA but affects crucial body areas necessary for daily living activities (i.e., face, palms of hands, soles of feet, or genitals)

3. Topical therapy (e.g., corticosteroids) is no longer effective or tolerated by the member*

• Less than 63 kg (138 lbs.): 0.8 mg/kg per week

• 63 kg or more: 50 mg once weekly

Polyarticular juvenile idiopathic arthritis (PJIA)

[previously known as juvenile rheumatoid arthritis (PJRA)]

When ALL of the following are met (“1”, “2”, and “3”):

1. Member is 2 years of age or older

2. Member’s disease is moderately to severely active

3. Member has had an inadequate response to, or has a contraindication to ONE or more csDMARD* (e.g., methotrexate, sulfasalazine, cyclosporine, leflunomide) (the specific contraindication must be provided)

• Less than 63 kg (138 lbs.): 0.8 mg/kg per week

• 63 kg or more: 50 mg once weekly

50 mg once weekly

Psoriatic arthritis (PsA)

[including both axial and non-axial (peripheral) PsA]

When BOTH of the following are met (“1” and “2”):

1. Member’s disease is active (i.e., persistent joint inflammation)

2. EITHER of the following based on the dominate disease type (“a” or “b”):

a. Axial PsA: Member has had an inadequate response to, or has a contraindication to at least TWO different NSAID therapies taken continuously for at least 4 weeks each* (e.g., celecoxib, diclofenac, ibuprofen, meloxicam, naproxen) ( the specific contraindications must be provided)

b. Peripheral PsA: Member has had an inadequate response to or has a contraindication to at least ONE NSAID therapy taken continuously for at least 4 weeks* (e.g., celecoxib, diclofenac, ibuprofen, meloxicam, naproxen) (the specific contraindication must be provided)

AND

Member has had an inadequate response to, or has a contraindication to methotrexate therapy, OR, if methotrexate is contraindicated, to another csDMARD* (e.g., cyclosporine, leflunomide, sulfasalazine) (the specific contraindication must be provided)

Rheumatoid arthritis (RA)

When ALL of the following are met (“1”, “2”, and “3’):

1. Member is 18 years of age or older

2. Member’s disease is moderately to severely active

3. Member has had an inadequate response (i.e., unable to achieve remission or low disease activity) to at least three continuous months of therapy with TWO or more csDMARDs (e.g., hydroxychloroquine, methotrexate, sulfasalazine, leflunomide) used in combination. A trial of csDMARD monotherapy for at least three continuous months is sufficient if the member has a contraindication to BOTH methotrexate AND either sulfasalazine or hydroxychloroquine* (the specific contraindications must be provided; pregnancy is not considered a contraindication to the use of sulfasalazine or hydroxychloroquine)

Approval duration: 6 months

ASAS, Assessment of SpondyloArthritis International Society; BSA, body surface area; csDMARD, conventional synthetic disease modifying anti-rheumatic drug; NSAID, non-steroidal anti-inflammatory;

*NOTE: if the member has had an inadequate response to previous biologic therapy, other than etanercept, (e.g., adalimumab) that is FDA-approved for the requested indication listed in Table 1, the member is not required to have had an inadequate response to non-biologic prerequisite therapy (e.g., for RA, if member has previously had an inadequate response to adalimumab but does not have a history of inadequate response to combination csDMARD, they do not have to try two csDMARDs in combination to meet medical necessity criteria).

Continuation of etanercept (Enbrel) meets the definition of medical necessity when ALL of the following are met (“1”, “2”, “3”, and “4”):

1. Member has demonstrated a beneficial clinical response to etanercept therapy

2. An authorization or reauthorization for etanercept has been previously approved by Florida Blue or another health plan in the past 2 years for the treatment of a condition listed in Table 1, OR the member previously met ALL indication-specific initiation criteria

3. Etanercept is NOT used in combination with ANY of the following

a. abatacept (Orencia)

b. adalimumab (Humira)

c. anakinra (Kineret)

d. apremilast (Otezla)

e. brodalumab (Siliq)

f. certolizumab (Cimzia)

g. guselkumab (Tremfya)

h. golimumab (Simponi, Simponi Aria)

i. infliximab products (Remicade, Inflectra, Renflexis)

j. ixekizumab (Taltz)

k. sarilumab (Kevzara)

l. secukinumab (Cosentyx)

m. tocilizumab (Actemra)

n. tofacitinib (Xeljanz, Xeljanz XR)

o. ustekinumab (Stelara)

p. vedolizumab (Entyvio)

4. The member’s dosage does not exceed:

a. Adults: 50 mg per week

b. Pediatrics: Less than 63 kg (138 lbs.): 0.8 mg/kg per week; 63 kg or more: 50 mg once weekly

Duration of approval: 1 year

Etanercept does NOT meet the definition of medical necessity for the following indication (for BOTH initiation and continuation of therapy):

• Wegener’s granulomatosis - Etanercept was ineffective vs. placebo in the randomized Wegener Granulomatosis Etanercept Trial (WGET) (n=181); in addition, etanercept was associated with an increased risk of solid tumors.

DOSAGE/ADMINISTRATION:

THIS INFORMATION IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND SHOULD NOT BE USED AS A SOURCE FOR MAKING PRESCRIBING OR OTHER MEDICAL DETERMINATIONS. PROVIDERS SHOULD REFER TO THE MANUFACTURER’S FULL PRESCRIBING INFORMATION FOR DOSAGE GUIDELINES AND OTHER INFORMATION RELATED TO THIS MEDICATION BEFORE MAKING ANY CLINICAL DECISIONS REGARDING ITS USAGE.

Table 2:

FDA-approved indications and recommended dosing

Indication

Dosage†

Plaque Psoriasis (adult, ≥18 years old)

• First 3 months: 50 mg twice weekly (given 3 to 4 days apart)

• After 3 months: 50 mg once weekly

Plaque Psoriasis (pediatric, 4 to 17 years old)

• Less than 63 kg (138 lbs.): 0.8 mg/kg per week

• 63 kg or more: 50 mg once weekly

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

(2 years and older)

Ankylosing Spondylitis

50 mg once weekly

Psoriatic Arthritis (PsA)

Rheumatoid Arthritis (RA)

Methotrexate, glucocorticoids, NSAIDs, or analgesics may be continued during treatment with etanercept.

Dose Adjustments: dosage adjustments are not required for members with hepatic or renal impairment.

Drug Availability:

Etanercept is supplied in the following dosage forms and strengths:

• 50 mg single-use prefilled syringe

• 50 mg single-use prefilled SureClick Autoinjector

50 mg Enbrel Mini single-dose prefilled cartridge (used in the AutoTouch Reusable Autoinjector)

• 25 mg single-use prefilled syringe

• 25 mg multiple-use vial

Store refrigerated at 36°F to 46°F (2°C to 8°C). DO NOT SHAKE. Store in the original carton to protect from light or physical damage. For convenience, storage of an individual dose tray containing Enbrel multi-use vial and diluent syringe at room temperature at 68°F to 77°F (20°C to 25°C) for a maximum single period of 14 days is permissible, with protection from light, sources of heat, and humidity.

PRECAUTIONS:

Boxed Warning

Infections: tuberculosis (TB), invasive fungal, and other opportunistic infections, some fatal, have occurred. Perform test for latent TB; if positive, start treatment for TB prior to starting therapy. Monitor all patients for active TB, even if initial tuberculin skin test is negative.

Malignancy: lymphoma and other malignancies, some fatal have been reported in children and adolescent individuals treated with TNF blockers including etanercept.

CONTRAINDICATIONS

• Enbrel is contraindicated in members with sepsis.

WARNINGS

Serious Infections: etanercept should not be initiated in members during an active infection. If an infection develops, monitor carefully, and discontinue etanercept if infection becomes serious.

Invasive fungal infections: If a member develops a systemic infection while on etanercept therapy, consider empiric antifungal therapy for those who reside or travel to regions where mycoses are endemic

Anaphylaxis: anaphylaxis or serious allergic reactions may occur.

Hepatitis B virus reactivation: members who are HBV caries should be monitored during and several months after therapy. If reactivation occurs during therapy, discontinue etanercept and initiate anti-viral therapy.

Demyelinating disease: exacerbation of new onset may occur

Cytopenia, pancytopenia: advise members to seek immediate medical attention if symptoms develop and consider discontinuing etanercept.

Heart failure: worsening or new onset heart failure may occur.

Lupus-like syndrome/Autoimmune hepatitis: discontinue etanercept if either syndrome develops.

Drug Interactions: avoid concomitant use with abatacept (Orencia®) and anakinra (Kineret®), due to increased risk of serious infection.

Live vaccines: Avoid administration of live vaccines (e.g., varicella and MMR) in members taking etanercept.

Pregnancy and Lactation

o Etanercept is classified as pregnancy category B. Developmental toxicity studies performed in animals have revealed no evidence of harm to the fetus. Use during pregnancy should occur only if clearly needed.

o Because many immunoglobulins are secreted in milk and the potential for serious adverse reactions exists, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

BILLING/CODING INFORMATION:

The following codes may be used to report Etanercept (Enbrel®).

HCPCS Coding:

J1438

injection, etanercept, 25 mg

ICD-10 Diagnosis Codes That Support Medical Necessity:

D89.810

Acute graft-versus-host disease

L40.0

Psoriasis vulgaris

L40.50 – L40.59

Arthropathic psoriasis

L73.2

Hidradenitis suppurativa

M05.00 – M05.09

Felty's syndrome

M05.10 – M05.19

Rheumatoid lung disease with rheumatoid arthritis

M05.20 – M05.29

Rheumatoid vasculitis with rheumatoid arthritis

M05.30 – M05.39

Rheumatoid heart disease with rheumatoid arthritis

M05.40 – M05.49

Rheumatoid myopathy with rheumatoid arthritis

M05.50 – M05.59

Rheumatoid polyneuropathy with rheumatoid arthritis

M05.60 – M05.69

Rheumatoid arthritis with involvement of other organs and systems

M05.70 – M05.79

Rheumatoid arthritis with rheumatoid factor without organ or systems involvement

M05.80 – M05.89

Other rheumatoid arthritis with rheumatoid factor

M05.9

Rheumatoid arthritis with rheumatoid factor, unspecified

M06.00 – M06.09

Rheumatoid arthritis without rheumatoid factor

M06.20 – M06.29

Rheumatoid bursitis

M06.30 – M06.39

Rheumatoid nodule

M06.80 – M06.89

Other specified rheumatoid arthritis

M06.9

Rheumatoid arthritis, unspecified

M08.09

Unspecified Juvenile rheumatoid arthritis, multiple sites

M08.1

Juvenile ankylosing spondylitis

M08.3

Juvenile rheumatoid arthritis (seronegative)

M08.89

Other juvenile arthritis, multiple sites

M 45.0 – M45.9

Ankylosing spondylitis

M46.81 – M46.89

Other specified inflammatory spondylopathies

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline review date.

Medicare Part D: Florida Blue has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline.

DEFINITIONS:

Axial PsA (a.k.a., psoriatic spondylitis): a subset of psoriatic arthritis that affects the spine (i.e., spondylitis) and/or spinal joints (e.g., the sacroiliac joint between the sacrum and ilium of pelvis). Axial PsA shares similar clinical findings to patients with ankylosing spondylitis (AS); however, patients with axial PsA are often less symptomatic, have asymmetric disease, and tend to have less severe disease. In addition, the psoriatic plaques or nail changes present in patients with axial PsA are absent in patients with AS. About 5% of PsA patients have exclusively axial involvement, and 20 to 50% have both spinal and peripheral involvement, with peripheral joint involvement being the predominant pattern.

Axial Spondyloarthritis (SpA): an inflammatory disease where the main symptom is back pain, and where the x-ray changes of sacroiliitis may or may not be present. In ankylosing spondylitis (AS), the x-ray changes are clearly present. In non-radiographic axial spondyloarthritis (nr-axSpA); the x-ray changes are not present but you have symptoms. It is thought that nr-axSpA may be an earlier form of AS.

DMARDs: An acronym for disease-modifying antirheumatic drugs. These are drugs that modify the rheumatic disease processes, and slow or inhibit structural damage to cartilage and bone. These drugs are unlike symptomatic treatments such as NSAIDs that do not alter disease progression. DMARDs can be further subcategorized. With the release of biologic agents (e.g., anti-TNF drugs), DMARDs were divided into either: (1) conventional, traditional, synthetic, or non-biological DMARDs; or as (2) biological DMARDs. However, with the release of newer targeted non-biologic drugs and biosimilars, DMARDs are now best categorized as: (1) conventional synthetic DMARDs (csDMARD) (e.g., MTX, sulfasalazine), (2) targeted synthetic DMARDs (tsDMARD) (e.g., tofacitinib, apremilast), and (3) biological DMARDs (bDMARD), which can be either a biosimilar DMARD (bsDMARD) or biological originator DMARD (boDMARD).

Hidradenitis suppurativa (HS) (a.k.a., acne inversa): a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. HS may have a large impact on quality of life, often causing depression, impaired sexual health, and embarrassment. Squamous cell carcinoma may arise from chronic (10-30 years of evolution) lesions. The main goals of treatment are to prevent the formation of new lesion, treat new lesions, and eliminate existing nodules and sinus tract to limit or prevent scar formation

Non-axial or peripheral PsA: a subset of psoriatic arthritis that does NOT affect the spine or spinal joints [e.g. elbow, wrist, knees, hands, feet, and digits (dactylitis)]. Peripheral involvement may be polyarticular (5 or more joints affected) or oligoarticular (a.k.a., pauciarticular) (4 or fewer joints affected). Approximately 95% of patients with PsA have involvement of the peripheral joints, predominantly the polyarticular form, whereas a minority have the oligoarticular form.

Plaque psoriasis: It is the most common form of psoriasis. It affects 80 to 90% of people with psoriasis. Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery white scaly skin. These areas are called plaques.

Psoriasis Area Severity Index (PASI): An index used to express the severity of psoriasis. It combines the severity (erythema, induration and desquamation) and percentage of affected area. The score ranges from 0 (no psoriasis on the body) to 72 (the most severe case of psoriasis). A score of 11 or greater suggests moderate-to-severe psoriasis. A web-based calculator can be found at: http://www.pasitraining.com

Psoriatic arthritis (PsA): joint inflammation that occurs in about 5% to 10% of people with psoriasis (a common skin disorder). It is a severe form of arthritis accompanied by inflammation, psoriasis of the skin or nails, and a negative test for rheumatoid factor. Enthesitis refers to inflammation of entheses, the site where ligaments or tendons insert into the bones. It is a distinctive feature of PsA and does not occur with other forms of arthritis. Common locations for enthesitis include the bottoms of the feet, the Achilles' tendons, and the places where ligaments attach to the ribs, spine, and pelvis.

Rheumatoid arthritis: An inflammatory disease of the synovium, or lining of the joint which results in pain, stiffness, and swelling of multiple joints. The inflammation may extend to other joints and cause bone and cartilage erosion, joint deformities, movement problems, and activity limitations.

RELATED GUIDELINES:

Abatacept (Orencia®), 09-J0000-67

Adalimumab (Humira®), 09-J0000-46

Anakinra (Kineret®), 09-J0000-45

Apremilast (Otezla), 09-J2000-19

Brodalumab (Siliq®) Injection, 09-J2000-74

Certolizumab Pegol (Cimzia®), 09-J0000-77

Golimumab (Simponi®, Simponi® Aria™), 09-J1000-11

Guselkumab (Tremfya), 09-J2000-87

Infliximab Products [infliximab (Remicade®), infliximab-dyyb (Inflectra®), and infliximab-abda (Renflexis®)], 09-J0000-39

Ixekizumab (Taltz), 09-J2000-62

Rituximab (Rituxan®), 09-J0000-59

Secukinumab (Cosentyx®), 09-J2000-30

Sarilumab (Kevzara), 09-J2000-87

Tocilizumab (Actemra®), 09-J1000-21

Tofacitinib (Xeljanz, Xeljanz XR) Tablets, 09-J1000-86

Ustekinumab (Stelara™), 09-J1000-16

Vedolizumab (Entyvio), 09-J2000-18

OTHER:

Table 3: Conventional Synthetic DMARDs

Generic Name

Brand Name

Auranofin (oral gold)

Ridaura

Azathioprine

Imuran

Cyclosporine

Neoral, Sandimmune

Hydroxychloroquine

Plaquenil

Leflunomide

Arava

Methotrexate

Rheumatrex, Trexall

Sulfasalazine

Azulfidine, Azulfidine EN-Tabs

Assessment of Spondyloarthritis International Society (ASAS) Diagnostic Criteria for Axial Spondylarthritis (SpA)

Patients with chronic (≥3 months) back pain, the onset of which occurs at <45 years of age, AND EITHER of the following:

1. Imaging arm:

a. Sacroiliitis on imaging*

AND

b. ≥1 SpA feature

2. Clinical arm:

a. HLA-B27 positive

AND

b. ≥2 other SpA features

SpA features:

• Inflammatory back pain

• Arthritis

• Enthesitis (heel)

• Uveitis

• Dactylitis

• Psoriasis

• Crohn’s/colitis

• Good response to NSAIDs

• Family history of SpA

• HLA-B27

• Elevated CRP

*Active (acute) inflammation on MRI highly suggestive of sacroiliitis associated with SpA, or definite radiographic sacroiliitis according to modified New York criteria

Physician global assessment (PGA) of HS

• Clear: no inflammatory or non-inflammatory nodules

• Minimal: Only the presence of non-inflammatory nodules

• Mild: Less than 5 inflammatory nodules or 1 abscess or draining fistula and no inflammatory nodules

• Moderate: Less than 5 inflammatory nodules or one abscess or draining fistula and one or more inflammatory nodules or 2–5 abscesses or draining fistulas and less than ten inflammatory nodules

• Severe: 2–5 abscesses or draining fistulas and ten or more inflammatory nodules

• Very severe: More than 5 abscesses or draining fistulas

Grading of Severity of Rheumatoid Arthritis

Severity

Criteria

Mild

Joint pain
Inflammation of at least 3 joints
No inflammation in tissues other than the joints
Usually, a negative result on a rheumatoid factor test
An elevated erythrocyte sedimentation rate (ESR) or C reactive protein (CRP) level
No evidence of bone or cartilage damage on x-rays

Moderate

Between 6 and 20 inflamed joints
Usually no inflammation in tissues other than the joints
An elevated ESR or CRP levels
A positive rheumatoid factor test or anti-cyclic citrullinated peptide (anti-CCP) antibodies
Evidence of inflammation but no evidence of bone damage on x-rays

Severe

More than 20 persistently inflamed joints or a rapid loss of functional abilities
Elevated ESR or CRP levels
Anemia related to chronic illness
Low blood albumin level
A positive rheumatoid factor test, often with a high level
Evidence of bone and cartilage damage on x-ray
Inflammation in tissues other than joints

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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 09/13/17.

GUIDELINE UPDATE INFORMATION:

04/15/01

New Medical Coverage Guideline.

05/15/03

Annual review.

10/15/03

Added active ankylosing spondylitis to the When Services Are Covered section.

01/01/05

Revised psoriasis language in the When Services Are Covered Section.

02/15/06

Updated when services are covered added statement: For reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with psoriatic arthritis. Deleted warnings and contraindications, added DMARD table under Other.

12/15/06

Reviewed; reformatted, added CPT-4 and ICD-9 coding, related guidelines, and updated links and references. MCG revised to include Medicare Part D as a program exception.

08/15/07

Reviewed: reformatted, maintained current coverage and limitations, updated related guidelines, updated internet links and updated references.

10/15/07

Revision; consisting of updating ICD-9 coding.

05/15/08

Revision; consisting of adding a black box warning under “PRECAUTIONS”.

10/15/08

Review and revision consisting of; updating description section, reformatted and updated references.

01/01/09

Annual HCPCS coding update: deleted code 90772; added code 96372.

10/15/09

Review and revision consisting of updating precautions, related guidelines and reference sections.

04/15/10

Revision; consisting of adding specific continuation criteria.

09/15/10

Review and revision; consisting of updating precautions and references.

01/15/11

Revision; consisting of adding ICD-10 codes.

04/01/11

Revision; consisting of adding dosage limitations.

09/15/11

Review and revision to guideline; consisting of updating references.

09/15/12

Review and revision to guideline; consisting of modifying continuation criteria, updating precautions, coding and references.

01/15/12

Revision to guideline; consisting of revising and reformatting the position statement and description, dosage/administration, and precautions sections; updating references.

04/15/13

Revision to guideline; consisting of revising position statement to include duration of approval and Orphan Drug indications.

09/15/13

Review and revision to guideline; consisting of revising position statement to include treatment of compendia supported off-label indications, updating references, program exceptions, and coding.

04/15/14

Revision to guideline; consisting of adding clarification statement and reformatting position statement.

09/15/14

Review and revision to guideline; consisting of reformatting position statement, updating references, coding and related guidelines.

09/15/15

Review and revision to guideline; consisting of updating description, position statement, dosage/administration, coding/billing, related guidelines, and references.

11/01/15

Revision: ICD-9 Codes deleted.

09/15/16

Review and revision to guideline consisting of updating description, position statement, dosage/administration, coding/billing, definitions, related guidelines, and references.

01/15/17

Revision to guideline consisting of updating description, position statement, dosage/administration, and references based on new pediatric plaque psoriasis indication.

10/15/17

Review and revision to guideline consisting of updating description, position statement, definitions, related guidelines, and references.

Date Printed: October 23, 2017: 02:17 AM