CurrentCignaPolicy N/A

Immunologicals - Asthma Preferred Specialty Management Policy

This policy governs prior authorization and preferred product sequencing for reslizumab (Cinqair), benralizumab (Fasenra), and mepolizumab (Nucala) when used as add-on maintenance treatment for patients with severe eosinophilic asthma under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyImmunologicals - Asthma Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 6, 2025

Key ActionSubmit prior authorization requests and required documentation; try a preferred product (Fasenra or Nucala) before requesting the non-preferred product (Cinqair) unless exception criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3agents listed

2preferred products

1non-preferred product

No criteria changeshistory note

Coverage Criteria for IL-5 Immunologicals

Policy Summary

PayerCigna

PolicyImmunologicals - Asthma Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 6, 2025

SourceLink

On This Page

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Cinqair (non-preferred) exception criteria

Non-preferred product (Cinqair) is covered when the exception criteria are met:

Cinqair exception criteria: Approve if the patient meets BOTH of the following (A and B)

From policy text

A: Patient meets the standard Immunologicals - Cinqair Prior Authorization Policy criteria

Refer to the standard Cinqair PA policy

i: Patient has tried ONE of Fasenra or Nucala
Preferred product trial
ii: Patient is currently receiving Cinqair
Continuation of current therapy

Offer review for preferred product: If patient meets standard Cinqair PA criteria but has not tried a preferred product, offer to review for a Preferred Product

Program encourages trial of preferred agents prior to non-preferred approval

Any exception request beyond the specified non-preferred product exception criteria for Cinqair is not medically necessary. The policy states that the Immunologicals - Asthma Preferred Specialty Management non-preferred product(s) are covered only when the listed exception criteria are met; any other exception is considered not medically necessary.

Requests for non-preferred products that do not meet the specified exception criteria for Cinqair are considered not medically necessary. The program requires patients to meet the standard Prior Authorization criteria and the defined exception conditions for approval; if those conditions are not satisfied, the request will be denied as not medically necessary.

Coding Guidance

Coding guidancemixed

affected codes

Placeholder note in policy instructing to use the most appropriate codes as of submission; specific CPT/HCPCS/NDC codes are in respective PA policies (not listed here).

Provider Actions, Prior Authorization, and Billing

Prior Authorization

Prior Authorization Required

Prior authorization required — All medications (Preferred and Non-Preferred) require meeting the respective standard Immunologicals prior authorization policy criteria.

Preferred Products: Fasenra, Nucala
Non-Preferred Product: Cinqair

Step Therapy

Step Therapy Requirement

Step therapy requirement — Patients must try one Preferred Product (Fasenra or Nucala) prior to approval of the Non-Preferred Product (Cinqair). If the patient meets the standard Immunologicals - Cinqair prior authorization criteria but has not tried a Preferred Product, offer review for a Preferred Product. Current Cinqair recipients who otherwise meet criteria may be approved.

Approve Cinqair if patient meets standard Immunologicals - Cinqair prior authorization criteria AND (has tried Fasenra or Nucala OR is currently receiving Cinqair).
If patient meets Cinqair PA criteria but has not tried a Preferred Product, offer review for a Preferred Product.

Documentation Required

Required Documentation and Coding

Required documentation and coding — Providers must submit requests in accordance with the applicable benefit plan and use the most appropriate diagnosis and procedure codes as of the submission date. Claims submitted without covered diagnosis/procedure codes under the applicable coverage policy may be denied.

Submit requests in accordance with the terms of the applicable benefit plan document.
When billing, use the most appropriate codes as of the date of submission.
Claims for services billed for conditions or diagnoses not covered under this policy will be denied.

Denial Risk

Coding-Related Denial Risk

Coding-related denial risk — Claims submitted without covered diagnosis/procedure codes under the applicable coverage policy may be denied as not covered.

Lack of covered code(s) at time of submission is grounds for denial.

Background

Cinqair (reslizumab), Fasenra (benralizumab), and Nucala (mepolizumab) are anti‑interleukin‑5 (IL‑5) monoclonal antibodies indicated as add‑on maintenance treatments for patients with severe eosinophilic asthma. Within this program, Fasenra and Nucala are the Preferred Products and Cinqair is the Non‑Preferred Product; the policy encourages use of the preferred agents and requires patients to meet the applicable prior authorization and exception criteria for non‑preferred therapy.

Definitions

IL-5 immunologicals — key facts

ClassAnti-interleukin-5 (IL-5) monoclonal antibodies

Included agentsCinqair (reslizumab), Fasenra (benralizumab), Nucala (mepolizumab)

Primary indicationAdd-on maintenance treatment for severe eosinophilic asthma

Age approvalsFasenra and Nucala: ≥6 years; Cinqair: ≥18 years

Additional indications (selected)Nucala: EGPA, hypereosinophilic syndrome, COPD, chronic rhinosinusitis with nasal polyps; Fasenra: EGPA