J2361, Injection, depemokimab-ulaa, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- General: Clinical documentation in the medical record supporting the diagnosis and that the patient meets all listed policy criteria for the specific indication (progress notes, consult notes, problem lists).
- EGPA (Fasenra and Nucala): documentation of diagnosis of EGPA and past medical history or presence of asthma; documentation of at least two EGPA-typical characteristics (histopathological evidence such as eosinophilic vasculitis, perivascular eosinophilic infiltration, eosinophil-rich granulomatous inflammation; neuropathy mono- or poly-; pulmonary infiltrates non-fixed; sino-nasal abnormality; cardiomyopathy by echo or MRI; glomerulonephritis; alveolar hemorrhage; palpable purpura; ANCA positive).
- EGPA: documentation of relapsing or refractory disease defined as either (a) relapsing disease — at least one EGPA relapse within past 2 years requiring additional/dose escalation of corticosteroids or immunosuppressant or hospitalization; OR (b) refractory disease — failure to attain remission within prior 6 months following induction treatment with standard therapy regimens.
- EGPA: documentation that patient is currently taking standard therapy (systemic glucocorticoids with or without immunosuppressive therapy such as cyclophosphamide or rituximab).
- EGPA: documentation that patient is not receiving the product in combination with excluded biologics for the same indication.
- Severe asthma (all agents): evidence of diagnosis of severe asthma and that asthma is uncontrolled or inadequately controlled per at least one defined criterion (ACQ/ACT scores, corticosteroid bursts history, ER/hospital visits, airflow limitation measures, or OCS dependence).
Key Coverage Criteria
- Cinqair (reslizumab) — add-on maintenance therapy for severe asthma in adults (≥18 years) with an eosinophilic phenotype when criteria below are met.
- Fasenra (benralizumab) — add-on maintenance therapy for severe asthma in patients aged ≥6 years with an eosinophilic phenotype when criteria below are met.
- Fasenra (benralizumab) — treatment of adult patients with eosinophilic granulomatosis with polyangiitis (EGPA) when criteria below are met (provider administration).
- Nucala (mepolizumab) — add-on maintenance therapy for severe asthma in patients aged ≥6 years with an eosinophilic phenotype when criteria below are met.
- Nucala (mepolizumab) — treatment of adult patients with eosinophilic granulomatosis with polyangiitis (EGPA) when criteria below are met (provider administration).
- Nucala (mepolizumab) — treatment of hypereosinophilic syndrome (HES) in adult and pediatric patients aged ≥12 years with HES ≥6 months without an identifiable non-hematologic secondary cause, when criteria below are met (provider administration).
3 Active Policies
UHC-POL-respiratory-interleukins, Respiratory Interleukins (Cinqair, Fasenra, & Nucala)
UMR-POL-UMR-respiratory-interleukins, Respiratory Interleukins (Cinqair, Fasenra, & Nucala)
SUREST-POL-SUREST-respiratory-interleukins, Respiratory Interleukins (Cinqair, Fasenra, & Nucala)
Related Codes
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