Jascayd (nerandomilast) — Coverage Criteria for Idiopathic Pulmonary Fibrosis (IPF) and Progressive Pulmonary Fibrosis (PPF)
Customize your policy alerts
Sign up for all Neighborhood Health Plan of Rhode Island policy alerts
Know when Neighborhood Health Plan of Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
Covers medical necessity criteria and authorization requirements for Jascayd (nerandomilast) for treatment of idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) in adults for Neighborhood Health Plan of Rhode Island members.
Jascayd (nerandomilast) is listed with FDA-approved indications for treatment of IPF and PPF with specific approval criteria.
Coverage Criteria for Jascayd (nerandomilast)
Initial Therapy — IPF
Covered when ALL of the following are met:
Authorization may be granted for 6 months.
Initial Therapy — PPF
Covered when ALL of the following are met:
Authorization may be granted for 6 months.
Continuation Therapy
Covered when ALL of the following are met:
Authorization period: 6 months.
Authorization period: 6 months.
All indications other than the FDA‑approved uses for Jascayd—specifically idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) in adults—are considered experimental/investigational and are not a covered benefit.
Use of Jascayd for clinical conditions outside the FDA‑approved indications of IPF and PPF in adults is considered not medically necessary/experimental and will not be covered.
Provider Requirements and Authorization
Prior Authorization Required
Prior authorization required for initiation. Initial approvals are for 6 months. Requests must meet diagnostic, age, and specialist criteria (pulmonologist involvement).
- Initial approval duration: 6 months
- Prescriber: pulmonologist or in consultation with a pulmonologist
- Member age: ≥ 18 years
- Diagnostic requirements: see documentation callout
Step Therapy / Prior Treatment Requirement
Step therapy / prior treatment required. Prior inadequate response, intolerance, or contraindication to specified therapies is required before authorization.
- For IPF: 6-month trial, intolerance, or contraindication to pirfenidone (Esbriet) or Ofev (nintedanib) is required
- For PPF: 6-month trial, intolerance, or contraindication to Ofev (nintedanib) is required
- If combination therapy is requested, documentation of disease progression on at least a 6-month trial of monotherapy at maximum tolerated dose is required
Required Clinical Documentation
Required clinical documentation. Include all items below with the authorization request to establish diagnosis and baseline status.
- Pulmonologist involvement: prescription by or consultation with a pulmonologist
- Age documentation: member is ≥ 18 years
- Diagnostic imaging/biopsy: HRCT of the chest and/or lung biopsy consistent with UIP for IPF; for non‑UIP patterns, HRCT plus supportive lung biopsy or multidisciplinary discussion
- For PPF: HRCT showing fibrosis affecting ≥ 10% of the lungs
- Baseline pulmonary function: documented baseline forced vital capacity (FVC)
- Evidence of progression for PPF: FVC decline ≥10% predicted, or FVC decline ≥5% and <10% with worsening symptoms or imaging, or worsening symptoms and increased fibrosis on HRCT
- Prior therapy documentation: records demonstrating a 6-month trial (or intolerance/contraindication) of required comparator agents as noted in step therapy
Non‑Approved Indications
Non‑approved indications. Uses other than the FDA‑approved indications for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) are considered experimental/investigational and are not covered.
- Covered FDA indications: IPF and PPF in adult patients
- All other indications: experimental/investigational — not a covered benefit
Missing Required Clinical Documentation
Missing required clinical documentation may result in denial. Denials are likely if key items are absent from the request.
- Missing HRCT report or lung biopsy supporting diagnosis
- Missing baseline FVC
- Missing documentation of prior 6‑month trials, intolerance, or contraindications to pirfenidone or nintedanib as applicable
- Missing pulmonologist prescription or consultation note
- Incomplete evidence of progression for PPF (e.g., no FVC decline data or imaging/symptom documentation)
Product Listing and Key Clinical Thresholds
| Jascayd 9mg | Jascayd (nerandomilast) 9 mg tablet — quantity limit reference |
| Jascayd 18mg | Jascayd (nerandomilast) 18 mg tablet — quantity limit reference |
Definitions and Diagnostic Terms
Background
Idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) are fibrosing interstitial lung diseases that primarily affect adults and are characterized by a progressive decline in lung function. High‑resolution chest imaging (HRCT) and, when indicated, lung biopsy with multidisciplinary assessment are central to diagnosis. For PPF, progression is documented by objective measures such as decline in forced vital capacity (FVC), worsening respiratory symptoms, and increased extent of fibrosis on imaging—features that drive the determination of medical necessity for antifibrotic therapy.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.