CurrentCignaPolicy v071525

Cinqair (reslizumab) prior authorization for severe eosinophilic asthma

This document is a Cigna prior authorization form and coverage policy checklist governing requests for Cinqair (reslizumab) infusion therapy for patients (primarily with asthma) and instructs providers what clinical information and documentation are required for coverage decisions.

Policy Summary

PayerCigna

PolicyCinqair (reslizumab) prior authorization for severe eosinophilic asthma

Policy CodePolicy v071525

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a prior authorization request with the completed form including clinical criteria, documentation of blood eosinophil count, prior controller therapy trials, and prior therapy responses.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

>= 400eosinophil threshold

>= 3 monthsmin prior controller duration

>= 2/yruncontrolled asthma definition

Coverage Criteria for Cinqair (reslizumab)

Initial therapy

Covered when ALL of the following are met for initial therapy

Initial therapy criteria: Patient has blood eosinophil count >= 400 cells per microliter within the previous 4 weeks or prior to treatment with Cinqair or another monoclonal antibody therapy that may lower blood eosinophil levels; has received at least 3 consecutive months of combination therapy with BOTH: (A) an inhaled corticosteroid (medium- or high-dose) AND (B) at least one additional asthma controller or asthma maintenance medication (examples: inhaled long-acting beta2-agonists, inhaled long-acting muscarinic antagonists, or a monoclonal antibody); asthma was uncontrolled at baseline as defined by ONE of the following: (1) two or more asthma exacerbations requiring systemic corticosteroids in the previous year, OR (2) one or more asthma exacerbations requiring hospitalization, emergency department, or urgent care visit in the previous year, OR (3) asthma that worsens upon tapering of oral (systemic) corticosteroid therapy; medication is prescribed by or in consultation with an allergist, immunologist, or pulmonologist; document prior trials of covered alternatives (Nucala, Fasenra) and provide dates, durations, responses, or reasons alternatives were not tried.see node text

Form includes objective lung function and challenge test options as supplementary evidence of asthma diagnosis and reversibility

Continuation therapy

Policy Summary

PayerCigna

PolicyCinqair (reslizumab) prior authorization for severe eosinophilic asthma

Policy CodePolicy v071525

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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Requests may be considered not medically necessary when the form criteria are not met. Examples include when the patient does not have a documented blood eosinophil count of >= 400 cells per microliter within the prior 4 weeks (or prior to therapy that may lower eosinophils), when the patient has not received at least 3 consecutive months of combination therapy with a medium- or high-dose inhaled corticosteroid plus at least one additional controller, or when the patient does not meet the form's definitions of uncontrolled asthma (for example, fewer than 2 exacerbations requiring systemic corticosteroids in the prior year and no qualifying hospital/ED/urgent care exacerbation or inability to taper systemic corticosteroids).

Additional clinical requirements on the form that, if unmet, can lead to denial include absence of documented objective lung function or challenge-test evidence when requested (FEV1 criteria or positive bronchial/exercise challenge) and lack of documentation that the prescribing clinician is an allergist, immunologist, or pulmonologist when required for the indication.

Provider Action Items and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Submit the completed prior authorization form (or submit electronically via CoverMyMeds or SureScripts) that includes all required clinical criteria and supporting documentation. Requests without a completed form or lacking essential clinical information may be delayed or denied.

Submit via www.covermymeds.com or SureScripts in your EHR.
Standard response time: 5 business days; call to expedite urgent requests.

Step Therapy

Step Therapy / Alternatives

Step therapy: Document trials of covered alternatives and outcomes before approval for the requested biologic when applicable. The covered alternatives to be tried and documented are Nucala (mepolizumab) and Fasenra (benralizumab). For each alternative tried, include drug name and strength, dates taken, duration (minimums if applicable), clinical response, and any intolerances or adverse reactions. If an alternative was not tried, provide clinical rationale why the patient cannot use that alternative.

List each alternative tried with start and stop dates and documented outcome.
If an alternative was not trialed, explain contraindication, intolerance, prior severe adverse reaction, or other clinical reason.

Documentation Required

Required Documentation

Required documentation to support the request includes complete patient and prescriber identifiers, medication directions (dose, quantity, duration), ICD-10 diagnosis code, relevant clinical notes, and supporting laboratory data. For initial requests include blood eosinophil count, history of controller therapy trials, and exacerbation history. For continuation requests include dates of prior therapy and documentation of clinical response.

Patient identifiers: Cigna ID, name, DOB, address, phone.
Prescriber identifiers: name, specialty, NPI/DEA or TIN, office contact, phone, fax.
Medication details: drug, dose, directions, quantity, J-code if applicable, duration.
Clinical data: ICD-10 diagnosis, blood eosinophil count (see denial triggers), documentation of ≥3 months of combination controller therapy when required, exacerbation history, and response to prior biologic or current biologic therapy.

Denial Risk

Potential Denial Triggers

Potential denial triggers include missing or insufficient clinical information and failure to meet initial criteria. Examples: lack of a documented blood eosinophil count ≥ 400 cells/µL (when required for initial approval); no documented trial of required controller therapy (≥3 consecutive months of medium- or high-dose inhaled corticosteroid plus at least one additional controller); absence of documented trials or rationale for covered alternatives (Nucala, Fasenra); or missing prescriber/patient identifiers and medication directions.

Missing blood eosinophil ≥ 400 cells/µL within prior 4 weeks (or prior to other biologic therapy) may lead to denial.
No documentation of ≥3 months of appropriate combination controller therapy.
No documented trial of, or documented contraindication to, covered alternatives (Nucala, Fasenra).
Incomplete or missing form fields (patient/prescriber identifiers, drug dose, quantity, ICD-10) may delay or result in denial.

Background

Cinqair (reslizumab) is a monoclonal antibody therapy used for patients with severe eosinophilic asthma. The prior authorization form is structured to confirm the eosinophilic phenotype (notably a blood eosinophil count of >= 400 cells/µL for initial therapy), prior controller treatment history, objective lung function or challenge testing where applicable, and history of exacerbations to establish that asthma was uncontrolled at baseline.

The form also captures insurer-focused requirements: documentation of prior trials of covered alternatives (for example, Nucala and Fasenra), verification that the prescriber is an appropriate specialist (allergist, immunologist, or pulmonologist), and supporting clinical measures of response for continuation requests (for patients treated ≥6 months). These items guide coverage decisions and align with the policy’s intent to authorize Cinqair when the patient meets the defined severe eosinophilic asthma criteria.

Definitions and Key Criteria

inv-12: Blood eosinophil criterion for initial therapy

Initial therapy eosinophil requirement>= 400 cells/µL measured within the previous 4 weeks or prior to therapy with a monoclonal antibody

Prior controller therapyAt least 3 consecutive months of combination therapy including a medium- or high-dose inhaled corticosteroid AND at least one additional asthma controller/maintenance medication

Primary definition of uncontrolled asthma>= 2 exacerbations requiring systemic corticosteroids in the previous year (baseline prior to monoclonal antibody therapy)

inv-13: Uncontrolled asthma (primary definition)

Primary uncontrolled asthma definition>= 2 exacerbations requiring systemic corticosteroids in the previous year (baseline prior to receiving monoclonal antibody therapy)

Alternate uncontrolled asthma criteriaOne or more exacerbations requiring hospitalization, ED, or urgent care in the previous year

Steroid-taper criterionAsthma that worsens upon tapering of oral (systemic) corticosteroid therapy

OpenPayer

Cinqair (reslizumab) prior authorization for severe eosinophilic asthma

Coverage Criteria for Cinqair (reslizumab)

Billing and Diagnostic Codes

Provider Action Items and Submission Requirements

Background

Definitions and Key Criteria