Iobenguane I-131 (Azedra) Form

Iobenguane I-131 (Azedra®) injection is a radioactive agent. FDA Approved Indication(s) Azedra is indicated for the treatment of adult and pediatric patients 12 years and older with iobenguane scan positive, unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma who require systemic anticancer therapy. Policy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.
It is the policy of health plans affiliated with Centene Corporation® that Azedra is medically necessary when the following criteria are met:
I. Initial Approval Criteria
A. Pheochromocytoma and Paraganglioma (must meet all):

1. Diagnosis of pheochromocytoma or paraganlioma;
2. Prescribed by or in consultation with an oncologist;
3. Age ≥ 12 years;
4. Tumor is unresectable, locally advanced, or metastatic;
5. Member currently receives medication to control tumor secretion of catecholamines (e.g., epinephrine, norepinephrine, dopamine) and related symptoms (e.g., hypertension, arrhythmia, hyperglycemia);
   6. Documentation of positive metaiodobenzylguanidine (MIBG) scan;

6. Concurrent radiopharmaceuticals have not been prescribed (e.g., Lutathera® [lutetium lu-177 dotatate]);

   8. Request meets one of the following (a or b):* a. Dose does not exceed (i or ii): i. Dosimetric dose (one dose only - dosimetry is used to calculate therapeutic dosing and must be administered first): a) For member weight > 50 kg: 185 to 222 MBq (5 to 6 mCi); b) For member weight ≤ 50 kg: 3.7 MBq/kg (0.1 mCi/kg); ii. Therapeutic dose (up to two doses at least 90 days apart): a) For member weight > 62.5 kg: 18,500 MBq/kg (500 mCi); b) For member weight ≤ 62.5 kg: 296 MBq/kg (8 mCi/kg); Page 1 of 7

   CLINICAL POLICY Iobenguane I 131 b. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). *Prescribed regimen must be FDA-approved or recommended by NCCN.
   Approval duration: Medicaid/HIM – 6 months (one dosimetric dose and up to two therapeutic doses) Commercial – 6 months or to the member’s renewal date, whichever is longer (one dosimetric dose and up to two therapeutic doses) B. Other diagnoses/indications (must meet 1 or 2):

   1. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b): a. For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace, and CP.PMN.255 for Medicaid; or b. For drugs NOT on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace, and CP.PMN.16 for Medicaid; or
   2. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid.
      II. Continued Therapy A. Pheochromocytoma and Paraganglioma (must meet all):
   3. Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Azedra for a covered indication and has received this medication for at least 30 days;
   4. Member is responding positively to therapy as evidenced by but not limited to reduction or discontinuation of medication needed to control catecholamine-related symptoms (e.g., reduction in hypertension medication);
   5. If request is for a dose increase, request meets one of the following (a or b): a. New dose does not exceed (i or ii): i. Dosimetric dose (one dose only - dosimetry is used to calculate therapeutic dosing and must be administered first): a) For member weight > 50 kg: 185 to 222 MBq (5 to 6 mCi); b) For member weight ≤ 50 kg: 3.7 MBq/kg (0.1 mCi/kg); ii. Therapeutic dose (up to two doses at least 90 days apart): a) For member weight > 62.5 kg: 18,500 MBq/kg (500 mCi); b) For member weight ≤ 62.5 kg: 296 MBq/kg (8 mCi/kg); b. New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). Prescribed regimen must be FDA-approved or recommended by NCCN.
      Approval duration: Page 2 of 7

   CLINICAL POLICY Iobenguane I 131 Medicaid/HIM – 6 months (one dosimetric dose and up to two therapeutic doses) Commercial – 6 months or to the member’s renewal date, whichever is longer (one dosimetric dose and up to two therapeutic doses) B. Other diagnoses/indications (must meet 1 or 2):

   1. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b): a. For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace, and CP.PMN.255 for Medicaid; or b. For drugs NOT on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace, and CP.PMN.16 for Medicaid; or
   2. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid.
      III. Diagnoses/Indications for which coverage is NOT authorized:
      A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policies – CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid or evidence of coverage documents.
      IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key FDA: Food and Drug Administration MBq: megabecquerel mCi: millicurie Appendix B: Therapeutic Alternatives
      Not applicable. NCCN: National Comprehensive Cancer Network Appendix C: Contraindications/Boxed Warnings None reported
      Appendix D: Dosing Guidelines (Azedra Website and Prescribing Information) • The manufacturer’s website offers the following PDF dosing and administration resources (https://azedra.com/site-setup-resources/): o Dose preparation guide o Dosing and administration guide o Dosimetry guide Page 3 of 7

   CLINICAL POLICY Iobenguane I 131 o Patient schedule and release instructions o Patient treatment card • Prescribing information: o Azedra is a radiopharmaceutical. Handle with appropriate safety measures to minimize radiation exposure. Use waterproof gloves and effective radiation shielding when handling Azedra. Radiopharmaceuticals, including Azedra, should be used by or under the control of physicians who are qualified by specific training and experience in the safe use and handling of radiopharmaceuticals, and whose experience and training have been approved by the appropriate governmental agency authorized to license the use of radiopharmaceuticals [i.e., Nuclear Regulatory Commission and state Health Departments].
   o Verify pregnancy status in females of reproductive potential prior to administering Azedra. o Do not administer if platelet count is less than 80,000/mcL or absolute neutrophil count is less than 1,200/mcL. o Block thyroid prior to administering Azedra. o Based on the mechanism of action of iobenguane, drugs that reduce catecholamine uptake or that deplete catecholamine stores may interfere with iobenguane uptake into cells and therefore interfere with dosimetry calculations or the efficacy of Azedra. These drugs were not permitted in clinical trials that assessed the safety and efficacy of Azedra. Discontinue drugs that reduce catecholamine uptake or deplete catecholamine stores, such as those listed below, for at least 5 half-lives before administration of either the dosimetry or a therapeutic dose of Azedra. Do not administer these drugs until at least 7 days after each Azedra dose (see Package Insert

   • Dosage and Administration (2.3) and Drugs that Reduce Catecholamine Uptake or Deplete Stores (7.1)).
      CNS stimulants or amphetamines (e.g. cocaine, methylphenidate, dextroamphetamine)
      Norepinephrine and dopamine reuptake inhibitors (e.g. phentermine)
      Norepinephrine and serotonin reuptake inhibitors (e.g. tramadol)
      Monoamine oxidase inhibitors (e.g. phenelzine and linezolid)
      Central monoamine depleting drugs (e.g. reserpine)
      Non-select beta adrenergic blocking drugs (e.g. labetalol)
      Alpha agonists or alpha/beta agonists (e.g. pseudoephedrine, phenylephrine, ephedrine, phenylpropanolamine, naphazoline)
      Tricyclic antidepressants or norepinephrine reuptake inhibitors (e.g. amitriptyline, bupropion, duloxetine, mirtazapine, venlafaxine)
      Botanicals that may inhibit reuptake of norepinephrine, serotonin or dopamine (e.g. ephedra, ma huang, St John’s Wort, yohimbine) V. Dosage and Administration
     Indication Dosing Regimen Maximum Dose Pheochromocytoma or paraganglioma Dosing regimen (see dosing guidelines at Appendix D): See regimen Page 4 of 7

   CLINICAL POLICY Iobenguane I 131 Indication Dosing Regimen Maximum Dose Administer Azedra intravenously as a dosimetric dose followed by up to two therapeutic doses administered at least 90 days apart. • Recommended dosimetric dose:
   o Patients greater than 50 kg: 185 to 222 MBq (5 to 6 mCi)
   o Patients 50 kg or less: 3.7 MBq/kg (0.1 mCi/kg)
   • Recommended therapeutic dose (adjust Azedra therapeutic dose(s) based on radiation dose estimates results from dosimetry): o Patients greater than 62.5 kg: 18,500 MBq (500 mCi)
   o Patients 62.5 kg or less: 296 MBq/kg (8 mCi/kg)
   VI. Product Availability
   Single-dose vial: 555 MBq/mL (15 mCi/ml) at TOC as a clear solution
   VII.