Inebilizumab-cdon (Uplizna^TM) is a CD-19 directed monoclonal antibody. Inebilizumab (Uplizna) is presumed to bind to CD-19 receptors on pre-B and mature B lymphocytes leading to antibody-dependent cellular cytolysis.

Inebilizumab (Uplizna) requires hepatitis B and tuberculosis screening prior to the first dose. It also requires premedication with a corticosteroid, an antihistamine and an antipyrectic prior to each dose. 

Inebilizumab (Uplizna) may be considered medically necessary when the following criteria are met:

• Individual 18 years of age or older; and
• Individual diagnosed with neuromyelitis optica spectrum disorder (NMOSD) as confirmed by ANY of the following:
  • Optic neuritis; or
  • Acute myelitis; or
  • Area postrema syndrome: episode of otherwise unexplained hiccups or nausea and vomiting; or
  • Acute brainstem syndrome; or
  • Symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions; or
  • Symptomatic cerebral syndrome with NMOSD-typical brain lesions; and
• Individual is anti-aquaporin-4 (AQP4) antibody positive; and
• Diagnosis of multiple sclerosis (MS) or other diagnoses have been ruled out; and
• Prescribed by or in consultation with a neurologist or other healthcare provider experienced in treating NMOSD; and
• Individual is not concomitantly being treated with disease modifying therapies for MS or NMOSD; and
• Initial authorization will be for 6 months.

Reauthorization Criteria

Reauthorization of inebilizumab (Uplizna) may be considered medically necessary when the following criteria are met:

• Individual diagnosed with AQP4 antibody positive NMOSD; and
• Prescribed by or in consultation with a neurologist or other healthcare provider experienced in treating NMOSD; and
• Individual has demonstrated a positive clinical response from baseline as demonstrated by a documented reduction in the signs and symptoms of NMOSD and/or reduction in the number and/or severity of relapses; and
• Reauthorization will be for no longer than 12 months.

Inebilizumab (Uplizna) for any other indication is considered not medically necessary.

Inebilizumab (Uplizna) may be considered medically necessary for individuals 18 years of age and older when applicable clinical criteria for individual medication policies are met and when administered in a physician’s office not affiliated with a hospital, specialized infusion centers not affiliated with a hospital or in the home. 

Outpatient facility (Outpatient Hospital IV Infusion Department or Hospital-based Outpatient Clinical Level of Care) administration may be considered medically necessary if ANY of the following criteria are present to indicate the member is medically unstable for infusions in other than an outpatient facility setting:

• Member’s home is considered unsuitable for care by the home infusion provider; or
• Individual’s medical status requires enhanced monitoring beyond that which would routinely be needed for infusion therapy; or
• Previous severe adverse reaction (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure) during or following administration of prescribed medication despite standard pre-medication; or
• Individual is receiving other medications that require close monitoring with a higher level of care (e.g., cytotoxic chemotherapy or blood products); or
• Individual is at high risk for complications due to medication administration (e.g., at risk for post-transplant complications, increased risk of infusion reactions due to presence of circulating antibodies, unstable vascular access, cardiopulmonary condition at risk for severe adverse reactions, unstable renal function with inability to safely tolerate IV volume loads, etc.); or 
• Individual is initiating therapy or re-initiating therapy after a period of at least 6 months with no therapy; or
• Physically and/or cognitively impaired AND a home caregiver is not available to comply with the required treatment regimen and schedule.

Home health services may be considered medically necessary when utilized for the administration of home infusion therapy and when provided by licensed eligible provider. Each case will be addressed on an individual basis.

The medications identified in this policy will be considered not medically necessary if administered in an unapproved hospital outpatient setting when an approved site of care is a viable option for treatment.

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.