CurrentAetnaPolicy N/A

Fasenra (benralizumab) Injectable Medication Precertification Request — Coverage Criteria

This document is Aetna's precertification/request form for Fasenra (benralizumab) injections and governs the information providers must submit for initiation or continuation of therapy for Aetna members.

Policy Summary

PayerAetna

PolicyFasenra (benralizumab) Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed precertification request using Aetna's form and include required clinical fields (baseline blood eosinophil count, prior therapy, and documentation of uncontrolled asthma) to support initiation or continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesdocument length

Required clinical fieldsrequired clinical fields

Precert phone/faxprecert contact

Specialist sign-offspecialist sign-off

Coverage Criteria

Initial Therapy

Initiation requests: covered when ALL of the following are documented

Initiation criteria: 1) Diagnosis of asthma (documented on the form).

From form checkbox: 'Does the patient have a diagnosis of asthma?'

Initiation criteria: 2) Baseline blood eosinophil count (cells/µL) is provided (baseline value before significant oral steroid use).cells per microliter

Form requests baseline blood eosinophil count for initiation

Evidence of uncontrolled asthma (one or more required)

A: Two or more asthma exacerbations requiring oral or injectable corticosteroid treatment within the past year.

Policy Summary

PayerAetna

PolicyFasenra (benralizumab) Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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B: One or more asthma exacerbations resulting in hospitalization or emergency medical care visit within the past year.

C: Poor symptom control within the past year (frequent symptoms or reliever use, activity limitation from asthma, or night wakening due to asthma).

Initiation criteria: 4) Inadequate asthma control despite treatment with an inhaled corticosteroid plus an additional controller at optimized doses (e.g., LABA, LAMA, leukotriene modifier, or sustained‑release theophylline).

Form asks whether patient had inadequate control despite ICS plus additional controller

Initiation criteria: 5) Prior use of another biologic drug indicated for asthma documented (Yes/No) where applicable.

Form asks if patient previously received another biologic (e.g., Dupixent, Nucala)

Initiation criteria: 6) Medication prescribed by or in consultation with an allergist, immunologist, or pulmonologist (documented on the form).

Initiation criteria: 7) Patient will continue maintenance asthma treatments (inhaled corticosteroids and additional controller) in combination with the requested medication (documented on the form).

Continuation Therapy

Continuation requests: covered when ALL of the following are documented

Continuation criteria: 1) Documentation that asthma control has improved on the requested medication as demonstrated by a reduction in the frequency and/or severity of symptoms and exacerbations (Yes on form).

Form asks whether asthma control has improved on treatment

Continuation criteria: 2) Documentation of reduction in the daily maintenance oral corticosteroid dose where applicable (Yes on form).

Form asks whether daily maintenance oral corticosteroid dose has been reduced

Continuation criteria: 3) Indicate if continuity is due to samples or a manufacturer's patient assistance program (documented on the form).

The form requires you to indicate if the requested medication will be used concurrently with another biologic or targeted synthetic drug for the same indication. Specifically, providers must answer whether the drug will be used concomitantly with any other biologic (for example, Adbry, Humira, Dupixent) or a targeted synthetic agent (for example, Rinvoq, Olumiant, Otezla, Xeljanz) for the same diagnosis. Documenting concurrent biologic or targeted synthetic use for the same indication is required on the precertification form and is a relevant consideration when evaluating coverage.

Precertification requests must include complete clinical information and clear documentation of the proposed administration setting. Requests may be denied or require additional review if fields are incomplete or illegible. The form asks whether the infusion will occur in an outpatient hospital setting and captures safety concerns that could affect the ability to safely deliver infusion therapy (for example, prior severe infusion-related adverse events, significant behavioral or cognitive impairment without caregiver access, or medical instability such as respiratory, cardiovascular, or renal conditions). If the information provided indicates the proposed setting cannot manage these infusion-safety risks, the plan may request further information or direct treatment to a different setting.

Coding

Administration CPT CodesCPT

Administration code(s) (CPT)

Administration code(s) (CPT) — providers must indicate applicable CPT codes

inv-06: Baseline blood eosinophil count — provider to indicate cells/µL value

Field nameBaseline blood eosinophil count

Unitscells per microliter (cells/μl)

Provider actionProvider must indicate the patient's baseline value (e.g., before significant oral steroid use)

ContextUsed for initiation requests to document eosinophilic phenotype and support medical necessity

Relation to prior therapyRequested alongside history of prior biologic use and measures of uncontrolled asthma

inv-12: blood eosinophil count (cells/µL) — baseline blood eosinophil count field

Field label on formPlease indicate the patient's baseline blood eosinophil count

Required entryNumeric value in cells per microliter

Timing noteBaseline defined as before significant oral steroid use

UseCollected for initiation requests to determine eligibility for Fasenra (benralizumab)

Associated questionsCaptured with prior biologic use and markers of uncontrolled asthma on the same form

Provider Actions / Submission Requirements

Documentation Required

Submission completeness

Precertification requests must be complete and legible. Incomplete, missing, or illegible fields may prevent review and the plan may request additional information or clarification before processing.

All required sections of the form must be completed: patient, insurance, prescriber, product, ICD diagnosis, and required clinical information fields.
Include contact information for who requested precertification (Phone, Fax) and indicate Start of treatment or Continuation of therapy with dates where applicable.
Use the Aetna precertification contact: Phone: 1-866-752-7021 (TTY: 711); FAX: 1-888-267-3277. For Medicare Advantage Part B, use the Medicare request form.

Documentation Required

Required form documentation

Providers must fully complete the precertification form fields and supply all required clinical documentation for both initiation and continuation requests. All fields must be completed and legible for precertification review.

Patient information: full name, address, contact numbers, DOB, allergies, weight, height, and email.
Prescriber information: name, credential (MD/DO/NP/PA), address, phone, fax, state license, NPI, DEA, UPIN, specialty, office contact and phone.
Product information: requested product (Fasenra/benralizumab), dose, and frequency.
Diagnosis information: primary ICD code and any secondary/other ICD codes.
Clinical information: complete sections for all requests and for initiation or continuation as applicable — including outpatient infusion setting, adverse events, behavioral/medical stability concerns, asthma diagnosis, concomitant biologic use, specialty prescriber/consultation, continued use of maintenance asthma therapies, baseline blood eosinophil count (for initiation), prior biologic drug history, history of exacerbations or hospitalizations, documentation of inadequate control despite inhaled corticosteroid plus an additional controller, systemic corticosteroid dependence, and for continuation requests evidence of improved asthma control and/or reduced maintenance oral steroid dose.
Attach supporting clinical records as needed (e.g., recent labs for eosinophil count, documentation of exacerbations or hospitalizations, prior therapy history).

Background

Fasenra (benralizumab) is an injectable biologic indicated for patients with severe eosinophilic asthma. The precertification form asks for baseline blood eosinophil count (e.g., prior to substantial oral steroid use) and documents key markers of uncontrolled asthma and prior biologic use to support medical necessity. The form also requires confirmation that the medication is prescribed by or in consultation with an allergist, immunologist, or pulmonologist and whether the patient will continue maintenance asthma treatments in combination with the biologic.

Definitions

inv-12: blood eosinophil count (cells/µL) — baseline blood eosinophil count definition/field

DefinitionBaseline blood eosinophil count = the patient's blood eosinophil count in cells per microliter measured before significant oral steroid use

Expected formatNumeric value reported as cells/μl on the precertification form

PurposeHelps document eosinophilic asthma phenotype and support initiation criteria for Fasenra

Where used on formRequired under 'For Initiation Requests (clinical documentation required)' section