CurrentAvMedPolicy N/A

Cinqair (reslizumab) IV — Prior Authorization Coverage Criteria

Prior authorization criteria and administrative requirements for AvMed coverage of Cinqair (reslizumab) intravenous therapy for members, including initial and reauthorization clinical criteria and documentation requirements; applies to providers requesting medical benefit coverage for the drug.

Policy Summary

PayerAvMed

PolicyCinqair (reslizumab) IV — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed medical prior authorization form with prescriber signature and supporting documentation including baseline peripheral blood eosinophil level and relevant chart notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum age

>400Eosinophil threshold

12 moInitial auth duration

3 mg/kg q4wDose/interval

Not permittedConcomitant biologics

Coverage Criteria for Cinqair (reslizumab)

Policy Summary

PayerAvMed

PolicyCinqair (reslizumab) IV — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed medical prior authorization form with prescriber signature and supporting documentation including baseline peripheral blood eosinophil level and relevant chart notes.

SourceLink

On This Page

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Initial Authorization

Covered when ALL of the following are met for initial authorization:

prescriber: Prescribed by or in consultation with an allergist, immunologist or pulmonologist

age: Member is 18 years of age or older>=18 years

eosinophils: Baseline (pre-Cinqair) peripheral blood eosinophil level of > 400 cells/microliter>400 cells/microliter

Submit labs collected within the past 12 months

controller_trial: Member is currently being treated with ONE of the following unless there is a contraindication or intolerance and must be compliant on therapy for at least 90 consecutive days within a year of request: (a) high-dose inhaled corticosteroid AND an additional asthma controller OR (b) one maximally dosed combination ICS/LABA product90 days

Trials will be verified via pharmacy claims/chart notes

exacerbation_history: Member has experienced ONE of: more than 2 exacerbations requiring additional medical treatment in the past 12 months OR any prior intubation for an asthma exacerbation OR baseline FEV1 < 80% predicted submitted within year of request

Reauthorization

Covered when ALL of the following are met for reauthorization:

clinical_response: Member has experienced a sustained positive clinical response to Cinqair as demonstrated by at least ONE of: increase in percent predicted FEV1 from baseline, reduction in dose of inhaled corticosteroids required, reduction in use of oral corticosteroids, reduction in asthma symptoms (chest tightness, coughing, shortness of breath, nocturnal awakenings)

Chart notes must be submitted

ongoing_controller: Member is currently being treated with ONE of the following unless there is a contraindication or intolerance: (a) high-dose inhaled corticosteroid AND an additional asthma controller OR (b) one maximally dosed combination ICS/LABA product

AvMed considers concomitant therapy of Cinqair (reslizumab) with other listed biologic agents to be experimental/investigational. Safety and efficacy of combining Cinqair with these agents have not been established, and such combinations will not be permitted.

Specifically, use of Cinqair in combination with Dupixent, Fasenra, Nucala, Tezspire, or Xolair is considered investigational and is not covered. If a member has an active authorization for any of these agents on file, subsequent requests for Cinqair will not be approved.

Provider Requirements and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Cinqair (reslizumab) IV requires prior authorization before administration. Submit the completed Medical Prior Authorization/Step-Edit Request form (prescribing physician signature required) and fax to 1-877-535-1391. Incomplete, incorrect, or illegible requests may delay processing or result in denial.

Prescribing physician must sign and clearly print name (preprinted stamps not valid).
For Medicare members, comply with applicable NCDs/LCDs per CMS. See Medicare Coverage Database.

Denial Risk

Concurrent Biologic Therapy — Not Permitted

Concurrent biologic therapy is not permitted. AvMed considers concomitant use of Cinqair with Dupixent, Fasenra, Nucala, Tezspire, or Xolair to be experimental/investigational; safety and efficacy have not been established. If the member has an active authorization for Dupixent®, Fasenra®, Nucala®, Tezspire™ or Xolair®, any request for Cinqair® will NOT be approved.

Requests will be denied when an active authorization for any listed biologic is on file.

Documentation Required

Required Supporting Documentation

Required supporting documentation must be submitted for each checked clinical criterion. Provide chart notes, relevant diagnostics, and lab results to support diagnosis, prior therapy trials, baseline and follow-up measurements, and observed clinical response. Trials may be verified via pharmacy claims and/or submitted chart notes; lack of documentation may result in denial.

Documentation to include: clinical progress notes, allergy/immunology or pulmonology consultation notes, and medication history (including dates and doses).
Baseline peripheral blood eosinophil count (pre-Cinqair) with date — labs must be within the past 12 months.
Baseline and follow-up pulmonary function testing showing FEV1 percent predicted (submit most recent within past 12 months).
Evidence of trial and failure or contraindication/intolerance to required controller therapies with dates — member must have been compliant for at least 90 consecutive days within the year prior to request.
Evidence of exacerbation history (e.g., ED visits, hospitalizations, intubation, oral corticosteroid bursts) if claimed.
For continuation requests, documentation of sustained positive clinical response (e.g., increased FEV1, reduced inhaled/oral corticosteroid dose, reduced symptoms) with supporting chart notes.

Documentation Required

Required Baseline Labs and Pulmonary Function Data

Baseline labs and pulmonary function data required: submit a pre-treatment peripheral blood eosinophil count showing > 400 cells/µL (collect after a trial and failure of at least 90 consecutive days of high‑dose ICS + LABA; labs must be within the past 12 months). Submit baseline FEV1 percent predicted documented within the past 12 months showing < 80% predicted if claimed.

Eosinophil count value and date of draw.
FEV1 percent predicted value and date of test.
Supporting notes documenting timing of controller therapy trial relative to lab draw.

Denial Risk

Incomplete/Incorrect Request Risk

Incomplete requests increase risk of delay or denial. Ensure all fields on the authorization form are complete, legible, and include provider contact information. The prescribing physician signature is required; preprinted stamps are not valid.

Fax completed form to 1-877-535-1391.
Include phone and fax numbers to avoid follow-up delays.

Step Therapy

Required Controller Therapy Trial

Required controller therapy trial — member must have trial and failure or documented contraindication/intolerance to specified controller therapies. Trial must show at least 90 consecutive days of compliance within the year prior to request.

Acceptable evidence: medication refill history, pharmacy claims, and chart notes documenting dates and adherence for a minimum 90-day consecutive period.
Specify whether trial was: high‑dose ICS + additional controller, or maximally dosed ICS/LABA product, and include doses.
If contraindication/intolerance is claimed, provide supporting clinical documentation.

OpenPayer

Cinqair (reslizumab) IV — Prior Authorization Coverage Criteria

Coverage Criteria for Cinqair (reslizumab)

Billing and Coding

Provider Requirements and Documentation

Background

Key Definitions