CurrentAvMedPolicy N/A

Fasenra (Pharmacy)

Prior authorization form and clinical criteria for pharmacy benefit coverage of Fasenra (benralizumab) including indications for severe eosinophilic asthma and eosinophilic granulomatosis with polyangiitis (EGPA); documents required for initial and reauthorization, dosing, quantity limits, and contraindicated concomitant biologic use.

Policy Summary

PayerAvMed

PolicyFasenra (Pharmacy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribers must complete and sign the pharmacy prior authorization/step-edit request form and fax to 1-305-671-0200 with required documentation including labs, diagnostics, chart notes; missing/incomplete information may delay authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Indications covered

1 syringe/56dQuantity limit

>=150Asthma eosinophil threshold

>10%/>1000EGPA eosinophil threshold

Coverage Summary

This policy is a pharmacy prior authorization for Fasenra (benralizumab) covering severe eosinophilic asthma (ages 6 years and older) and eosinophilic granulomatosis with polyangiitis (EGPA) under a covered_with_criteria stance. Medication is provided via a specified specialty pharmacy provider. Samples do not meet prior authorization/step-edit criteria and therefore cannot be used to initiate therapy. The form requires the prescriber to indicate whether the medication will be self-administered (pharmacy benefit) or administered by provider (medical benefit) so the appropriate benefit (pharmacy vs medical) is selected.

Quick reference — key thresholds

Peripheral blood eosinophil (severe eosinophilic asthma)>= 150 cells/microliter

EGPA baseline eosinophil>10% of total WBCs OR >1000 cells/mm3

Controller therapy compliance duration>= 90 consecutive days within a year of request

Stable oral corticosteroid prior to EGPA treatment>= 4 weeks on prednisone or equivalent (>7.5 mg/day)

Quantity limit1 syringe per 56 days (both strengths)

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required

Prescribers must complete and sign the pharmacy prior authorization/step-edit request form and fax it with required documentation (labs, diagnostics, chart notes) to 1-305-671-0200. Missing, incomplete, or illegible information may delay the authorization process.

Fax: 1-305-671-0200

Documentation Required

Submit baseline and follow-up labs and objective measures

Submit baseline peripheral blood eosinophil counts (within the past 12 months) and FEV1 or other objective measures. For EGPA, submit eosinophil counts with date, biopsy or other qualifying diagnostic findings, and disease activity scores (e.g., BVAS, VDI, FEV1, FVC, ACQ-6).

Billing Rule

Benefit selection

Indicate on the form whether the medication will be self-administered (pharmacy benefit) or administered by the provider (medical benefit).

Denial Risk

Concomitant biologics prohibited

Concomitant use of Cinqair, Dupixent, Nucala, Tezspire, and Xolair with Fasenra is considered experimental/investigational and will not be permitted. If the member has an active authorization for one of these agents, subsequent requests for Fasenra will not be approved.

Documentation Required

Prior therapies verification

Previous therapies will be verified through pharmacy paid claims or submitted chart notes. Note that samples used to initiate therapy do not meet step edit/prior authorization criteria.

Background & Definitions

This policy contains the prior authorization form and clinical coverage criteria for Fasenra (benralizumab), including recommended dosing by age and weight for severe eosinophilic asthma and dosing for EGPA. A specialty pharmacy provider is specified for dispensing. The policy states that samples do not meet prior authorization/step-edit criteria and cannot be used to initiate therapy.

Failure of controller medications (as defined by policy): Blood eosinophil count >150 cells/microliter after at least 90 consecutive days of high‑dose inhaled corticosteroid (ICS) AND long‑acting beta‑2 agonist (LABA) therapy.

Policy Summary

PayerAvMed

PolicyFasenra (Pharmacy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Fasenra (Pharmacy)

Coverage Summary

Initial Authorization - Severe Eosinophilic Asthma (ages 6+)

Reauthorization - Severe Eosinophilic Asthma

Initial Authorization - EGPA (Eosinophilic Granulomatosis with Polyangiitis)

Reauthorization - EGPA

Applicable Codes & Quantity Limits

Provider Actions & Billing Rules

Background & Definitions