Print

Date Printed: October 17, 2017: 04:18 PM

Private Property of Blue Cross and Blue Shield of Florida.
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-J2000-18

Original Effective Date: 09/15/14

Reviewed: 09/13/17

Revised: 10/15/17

Subject: Vedolizumab (Entyvio®) Injection

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.

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

DESCRIPTION:

Vedolizumab (Entyvio) was approved by the US Food and Drug Administration (FDA) in May 2014 for the treatment of moderately to severely active ulcerative colitis (UC) and moderately to severely active Crohn’s disease in adults who have had an inadequate response with, lost response to, or were intolerant to a TNF blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids. Vedolizumab binds to and blocks the interaction between integrin alpha-4-beta-7 and mucosal addressin cell adhesion molecule-1 (MAdCAM-1) in the gut which inhibits the migration of specific memory T-lymphocytes across the endothelium into inflamed gastrointestinal parenchymal tissue. The action reduces the chronic inflammatory process present in both UC and Crohn’s disease. FDA approval was based on the results of three pivotal trials: GEMINI 1 (UC) and GEMINI 2 and GEMINI 3 (Crohn’s disease). Vedolizumab, as sponsored by the innovator drug company, has also received orphan drug designation by the FDA for the “prevention of graft versus host disease” in August 2016, and for the “treatment of graft versus host disease” in March 2017.

POSITION STATEMENT:

NOTE: If the member has had an inadequate response to previous biologic therapy, other than vedolizumab, 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 UC, if the member has previously had an inadequate response to infliximab, but does not have a history of inadequate response to corticosteroid and sulfasalazine use, they do not have to try these two drugs to meet medical necessity criteria).

Initiation of vedolizumab (Entyvio) meets the definition of medical necessity when ALL of the following are met (“1”, “2”, and “3”):

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

2. Vedolizumab 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. etanercept (Enbrel)

h. golimumab (Simponi, Simponi Aria)

i. guselkumab (Tremfya)

j. infliximab products (Remicade, Inflectra, Renflexis)

k. ixekizumab (Taltz)

l. sarilumab (Kevzara)

m. secukinumab (Cosentyx)

n. tocilizumab (Actemra)

o. tofacitinib (Xeljanz, Xeljanz XR)

p. ustekinumab (Stelara)

3. The member is 12 years of age or older

Table 1

Indications and Specific Criteria

Indication

Specific Criteria

Maximum Allowable Dose

Crohn’s disease (CD)

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

1. Member has a diagnosis of moderately to severely active CD [e.g., Crohn’s Disease Activity Index (CDAI) greater than 220 points]

2. Member has had an inadequate response to at least ONE or has contraindications to ALL of the following treatments* (the specific contraindication(s) must be provided):

a. azathioprine

b. mercaptopurine (6-MP)

c. methotrexate

d. systemic corticosteroid (e.g. oral prednisone, IV methylprednisolone)

Initial

300 mg at week 0, 2, 6 and 14

Maintenance:

300 mg every 8 weeks starting on week 22

Ulcerative colitis (UC)

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

1. Member’s disease is moderately to severely active

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

a. Member has had an inadequate response to, or has a contraindication to systemic corticosteroid therapy (the specific contraindication must be provided)

b. Member is dependent on systemic corticosteroids [i.e., unable to successfully taper corticosteroids to less than 10 mg of prednisone (or equivalent) within 3 months of initiation without return of symptoms]

3. Member has had an inadequate response to ANY, or has a contraindication to ALL of the following* (the specific contraindications must be provided):

a. Oral aminosalicylates (i.e., sulfasalazine, olsalazine, mesalamine, or balsalazide)

b. Topical aminosalicylates (e.g., enema or suppository)

c. Thiopurine therapy (e.g., azathioprine or 6-mercaptopurine [6-MP])

Initial:

300 mg at week 0, 2, 6 and 14

Maintenance:

300 mg every 8 weeks starting on week 22

Orphan Indications

Graft verus host disease (GVHD) – prevention and treatment

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

1. Member will receive an allogenic HSCT the day following the first dose

2. The use of conventional treatment with methotrexate and a calcineurin inhibitor needs to be avoided

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

1. The member has previously received an allogenic HSCT

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

Prevention:

300 mg on day -1 before HSCT, then day 13 and day 42 (e.g., weeks 0, 2, and 6). Not to exceed 3 total dosages.

Treatment:

Initial - 300 mg at weeks 0, 2, 6

Maintenance – 300 mg every 4 weeks starting at week 10

Duration of approval: 14 weeks

HSCT, hemapoietic stem cell transplant

*NOTE: If the member has had an inadequate response to previous biologic therapy, other than vedolizumab, that is FDA-approved for the requested indication listed in Table 1, the member is not required to have had an inadequate response to additional non-biologic prerequisite therapy (e.g., for UC, if the member has previously had an inadequate response to infliximab, but does not have a history of inadequate response to corticosteroid and sulfasalazine use, they do not have to try these two drugs to meet medical necessity criteria).

Continuation of vedolizumab meets the definition of medical necessity when ALL of the following criteria are met:

1. An authorization or reauthorization for vedolizumab 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 (except for prevention of GVHD, OR the member previously met ALL indication-specific initiation criteria

2. The member has demonstrated a beneficial response to vedolizumab therapy, UNLESS the current dosage is 300 mg every 8 weeks and a reduced dosage interval may be appropriate (see criteria in bullet point 4bi below)

3. Vedolizumab will NOT be 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. etanercept (Enbrel)

h. golimumab (Simponi, Simponi Aria)

i. guselkumab (Tremfya)

j. infliximab products (Remicade, Inflectra, Renflexis)

k. ixekizumab (Taltz)

l. sarilumab (Kevzara)

m. secukinumab (Cosentyx)

n. tocilizumab (Actemra)

o. tofacitinib (Xeljanz)

p. ustekinumab (Stelara)

4. The dosage does not exceed EITHER of the following (“a” or “b”) unless previously approved by Florida Blue

a. The dosage does not exceed 300 mg every 8 weeks (if for CD or UC ), or 300 mg every 4 weeks (if for treatment of GVHD)

b. BOTH of the following if for CD or UC (‘i” and ii”):

i. Member has had an inadequate response to at least 6 months of continuous vedolizumab treatment in combination with an immunomodulator (i.e., methotrexate, azathioprine, or mercaptopurine). Vedolizumab monotherapy for at least 6 months is acceptable if the member has a contraindication to, or, persistent intolerable adverse effects to immunomodulator therapy [the specific contraindication(s) or adverse effect(s) must be provided]

ii. The dosage does not exceed 300 mg every 4 weeks

Approval duration: 1 year

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.

FDA-approved: Vedolizumab is indicated for the treatment of adults with either of the following:

  1. Moderately to severely active ulcerative colitis who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids
  2. Moderately to severely active Crohn’s disease who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids

The recommended dose for both indication sis 300 mg infused intravenously over approximately 30 minutes at weeks 0, 2, 6 and then every eight weeks. The manufacturer recommends discontinuation if there is no evidence of benefit at week 14.

Product availability: vedolizumab is supplied 300 mg/20 mL vial (must be reconstituted)

PRECAUTIONS:

Contraindication:

Previous serous or severe hypersensitivity reaction to vedolizumab or any of its excipients

Warnings:

  1. Hypersensitivity Reactions (including anaphylaxis): Discontinue vedolizumab if anaphylaxis or other serious allergic reactions occur.
  2. Infections: Treatment with vedolizumab is not recommended in persons with active, severe infections until the infections are controlled. Consider withholding vedolizumab in those who develop a severe infection while on treatment with vedolizumab.
  3. Progressive Multifocal Leukoencephalopathy: Although no cases have been observed in vedolizumab clinical trials, JCV infection resulting in progressive multifocal leukoencephalopathy (PML) and death has occurred in persons treated with another integrin receptor antagonist. A risk of PML cannot be ruled out. Monitor individuals administered vedolizumab for any new or worsening neurological signs or symptoms.

BILLING/CODING INFORMATION:

The following codes may be used to describe:

HCPCS Coding

J3380

Injection, vedolizumab, 1 mg

ICD-10 Diagnosis Codes That Support Medical Necessity

D89.810 – D89.813

Graft-versus-host disease

K50.00 – K50.919

Crohn’s disease (regional enteritis)

K51.00 – K51.919

Ulcerative colitis

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:

Crohn's Disease: is an inflammatory bowel disease characterized by severe, chronic inflammation of the intestinal wall or any portion of the gastrointestinal tract. The lower portion of the small intestine (ileum) and the rectum are most commonly affected by this disorder. Symptoms may include watery diarrhea and abdominal pain. The symptoms of Crohn's Disease can be difficult to manage and diagnosis is often delayed.

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).

Mild-Moderate Crohn’s Disease: Mild-moderate Crohn's disease applies to ambulatory members able to tolerate oral alimentation without manifestations of dehydration, toxicity (high fevers, rigors, prostration), abdominal tenderness, painful mass, obstruction, or >10% weight loss.

Moderate-Severe Crohn’s Disease: Moderate-severe disease applies to members who have failed to respond to treatment for mild-moderate disease or those with more prominent symptoms of fevers, significant weight loss, abdominal pain or tenderness, intermittent nausea or vomiting (without obstructive findings), or significant anemia.

Ulcerative colitis: a chronic inflammatory disease of the colon that is of unknown cause and is characterized by diarrhea with discharge of mucus and blood, cramping abdominal pain, and inflammation and edema of the mucous membrane with patches of ulceration.

RELATED GUIDELINES:

Abatacept (Orencia), 09-J0000-67

Adalimumab (Humira), 09-J0000-46

Anakinra (Kineret), 09-J0000-45

Etanercept (Enbrel), 09-J0000-38

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

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

Natalizumab (Tysabri®) Injection, 09-J0000-73

Rituximab (Rituxan), 09-J0000-59

Tocilizumab (Actemra®) Injection, 09-J1000-21

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

Ustekinumab (Stelara), 09-J1000-16

OTHER:

Table 2: Convetional Synthetic DMARDs

DMARD Generic Name

DMARD Brand Name

Auranofin (oral gold)

Ridaura

Azathioprine

Imuran

Cyclosporine

Neoral, Sandimmune

Hydroxychloroquine

Plaquenil

Leflunomide

Arava

Methotrexate

Rheumatrex, Trexall

Sulfasalazine

Azulfidine, Azulfidine EN-Tabs

REFERENCES:

  1. Bickston SJ, Behm BW, Tsoulis DJ, et al. Vedolizumab for induction and maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev. 2014 Aug 8;8:CD007571
  2. Buchner AM, Blonski W, Lichtenstein GR. Update on the management of Crohn’s disease. Curr Gastroenterol Rep 2011;13:465-74.
  3. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2017. Available at: www.clinicalpharmacilogy-ip.com. Accessed 8/8/17.
  4. Conrad MA, Stein RE, Maxwell EC, et al. Vedolizumab Therapy in Severe Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis. 2016 Oct;22(10):2425-31.
  5. Danese S, Fiorino G, Peyrin-Biroulet L, et al. Biological agents for moderately to severely active ulcerative colitis. Ann Intern Med 2014; 160: 704-11.
  6. Dignan FL, Clark A, Amrolia P, et al. Diagnosis and management of acute graft-versus-host disease. Br J Haematol 2012:15(1):30-45.
  7. Entyvio (vedolizumab) [package insert]. Takeda Pharmaceuticals America, Inc. Deerfield (IL): May 2014.
  8. FDA Orphan Drug Designations and Approvals [Internet]. Washington, D.C. [cited 2017 August 8]. Available from: http://www.accessdata.fda.gov/scripts/opdlisting/oopd/.
  9. Feagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med 2013;369(8):699-710.
  10. Hazelwood GS, Rezaie A, Borman M, et al. Comparative effectiveness of immunosuppressants and biologics for inducing and maintaining remission in Crohn’s disease: a network meta-analysis. Gastroenterology 2014; doi: 10.1053/j.gastro.2014.10.011.
  11. Kornbluth A, Sachar DB, et al. Erratum: ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010;105:500-23.
  12. LeBlanc K, Mosli M, Parker CE, MacDonald JK. The impact of biological interventions for ulcerative colitis on health-related quality of life. Cochrane Database Syst Rev. 2015 Sep 22;9:CD008655.
  13. Lichtenstein GR, Hanauer SB, Sanborn WJ, et al. Management of Crohn’s disease in adults. Am J Gastroenterol 2009;104(2):465-83.
  14. Micromedex® Healthcare Series [Internet Database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed 8/8/17.
  15. Sandborn WJ, Feagan BG, Rutgeerts P, et al. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2013;369(8):711-721.
  16. Singh N, Rabizadeh S, Jossen J, et al. Multi-Center Experience of Vedolizumab Effectiveness in Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis. 2016 Sep;22(9):2121-6.
  17. Terdiman JP, Gruss CB, Heidelbaugh JJ, et al. American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn's disease. Gastroenterology. 2013 Dec;145(6):1459-63.

COMMITTEE APPROVAL:

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

GUIDELINE UPDATE INFORMATION:

09/15/14

New Medical Coverage Guideline.

09/15/15

Review and revision to guideline; consisting of updating position statement, billing/coding, and references.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/16

Annual HCPCS coding update: added code J3380 and deleted codes C9026 and J3590.

09/15/16

Review and revision to guideline consisting of updating position statement and references.

5/15/17

Revision to guideline consisting of updating the references and position statement to allow use in adolescents (age 12 to 17 years).

10/15/17

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

Date Printed: October 17, 2017: 04:18 PM