CurrentBlue Cross Blue Shield - IowaPolicy 05.01.117

Cinqair (reslizumab) coverage for severe eosinophilic asthma

Defines clinical and administrative criteria for prior authorization, initial and continuation coverage, prescriber specialty, dosing limits, and billing code for Cinqair (reslizumab) for adults (≥18) with severe eosinophilic asthma when preferred biologics are inadequate or not tolerated.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyCinqair (reslizumab) coverage for severe eosinophilic asthma

Policy CodePolicy 05.01.117

Change TypeRevised

Effective DateJul 1, 2016

Next Review Date

Key ActionSubmit member chart/medical record showing pretreatment blood eosinophil count or systemic corticosteroid dependence and prior medication history for initial requests; for continuation, submit documentation supporting improvement in asthma control.

POLICY UPDATE CHANGES

Reviewed: October 2025 Revised: October 2025

1FDA-approved indication(s)

>=400 cells/µLEosinophil threshold for initial approval

6 monthsInitial authorization duration

12 monthsContinuation authorization duration

Coverage Summary

coverage_stance: covered_with_criteria; scope_summary: Defines clinical and administrative criteria for prior authorization, initial and continuation coverage, prescriber specialty, dosing limits, and billing code for Cinqair (reslizumab) for adults (≥18) with severe eosinophilic asthma when preferred biologics are inadequate or not tolerated. Note: Cinqair (reslizumab) is restricted to adults and is considered when preferred biologics (Dupixent, Fasenra, Nucala, Tezspire, Xolair) are inadequate or not tolerated.

Prescriber Specialty and Concomitant Use

Documentation Required

Prescriber specialty requirement

Medication must be prescribed by or in consultation with an allergist/immunologist or pulmonologist. If applicable, include documentation of the consultation in the member’s chart/medical record when submitting the request.

Allergist/immunologist
Pulmonologist

Not Medically Necessary / Exclusions

Denial Risk

Concomitant biologic use prohibition

Claims may be denied if Cinqair is used at the same time as other biologic therapies indicated for asthma. Do not concomitantly administer Cinqair with other asthma biologics.

Dupixent (dupilumab)
Fasenra (benralizumab)
Nucala (mepolizumab)
Tezspire (tezepelumab-ekko)
Xolair (omalizumab)
Affected billing code: J2786

Provider Actions / Prior Authorization

Prior Authorization

Prior authorization required with documentation

Prior authorization requests must include the member’s chart or medical record. For initial requests, submit pretreatment blood eosinophil count or documentation of systemic corticosteroid dependence, and prior medication history (drug, dose, frequency, duration). For continuation requests, submit documentation showing improvement in asthma control.

Affected billing code: J2786

Billing Rule

Dosing and administration limits

Approvals may be subject to dosing and administration limits consistent with FDA-approved labeling, accepted compendia, and evidence-based practice guidelines.

Reference billing code: J2786

Clinical Evidence & Definitions

Key RCTs: Reslizumab phase 3 trials demonstrated efficacy in patients with elevated blood eosinophil counts (Lancet Respir Med. 2015).

Product label: Cinqair package insert, February 2020.

Severe asthma: Asthma not controlled with medium-to-high dose inhaled corticosteroid plus an additional controller.

Systemic corticosteroid dependence: Chronic requirement for oral or injectable corticosteroids to control asthma (as documented in the medical record).

Background

Cinqair (reslizumab) is an anti-IL-5 monoclonal antibody indicated as add-on maintenance treatment for severe eosinophilic asthma in adults (≥18 years).

Policy positions Cinqair as a non-preferred, targeted product and prioritizes preferred biologics (Dupixent, Fasenra, Nucala, Tezspire, Xolair); coverage for Cinqair is provided only when preferred agents are inadequate or not tolerated and when the specified clinical criteria (e.g., eosinophil threshold, exacerbation history, background therapy, prescriber specialty) are met.