CurrentColorado Rocky Mountain Health PlansPolicy N/A

Fasenra (benralizumab) prior authorization form for severe eosinophilic asthma

A prior authorization / patient-specific request form used by Colorado Rocky Mountain Health Plans to document clinical criteria for initiation and continuation of Fasenra (benralizumab) for asthma (severe eosinophilic) and to collect beneficiary, prescriber, and drug information. It captures clinical questions that must be answered and requires prescriber signature and attached records for continuation.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFasenra (benralizumab) prior authorization form for severe eosinophilic asthma

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete the form and include beneficiary, prescriber, drug information, required labs/spirometry and attach medical records for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes for this policy.

8Required initial criteria items

3Continuation documentation items

Coverage Summary

Coverage: covered with criteria — Fasenra (benralizumab) is covered as an add-on maintenance therapy for severe eosinophilic asthma in patients aged >= 12 years when the documented clinical criteria on the prior authorization form are met, including required eosinophil thresholds, prior high‑dose inhaled corticosteroid plus long‑acting beta‑agonist therapy, exacerbation history, and spirometry evidence; prescriber signature and supporting records are required for continuation.

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Initial Therapy Criteria (New Authorization)

Asthma: New Therapy (Initial Authorization)

Covered when ALL of the following are met:

Top-level: All criteria must be met for initial authorization

Age and diagnosis

Age: Beneficiary age is 12 years or greater>= 12 years
Provider must check Yes
Diagnosis of severe eosinophilic asthma
Provider must check Yes

Eosinophil criteria

Option A: Pre-treatment serum eosinophil count >= 150 cells/mcL within past 6 weeks>= 150 cells/mcL within 6 weeks
Option B: Pre-treatment serum eosinophil count >= 300 cells/mcL within 12 months>= 300 cells/mcL within 12 months
Option C: Sputum eosinophil count > 3%> 3%

Prior controller therapy: Inadequate control after minimum of 3 months of high-dose inhaled corticosteroid plus a long-acting beta-agonistMinimum 3 months

Provider must document prior therapy and duration

Exacerbation / hospitalization (ONE of)

Exacerbation: Two or more asthma exacerbations requiring oral/systemic corticosteroids in past 12 months
Hospitalization: Asthma exacerbation requiring hospitalization in past 12 months

Lung function: Prebronchodilator FEV1 below 80% in adults (below 90% in adolescents)FEV1 <80% adults; <90% adolescents

Provider must list FEV1 value

Intended use: Fasenra is intended as add-on maintenance therapy (not for acute relief/status asthmaticus)

Provider must confirm Not for acute bronchospasm or status asthmaticus; not used as dual therapy with other monoclonal antibodies

Exclusions (must be NO)

Other eosinophilic conditions: Fasenra being used for treatment of other eosinophilic conditions (must be No)
Acute bronchospasm/status asthmaticus: Fasenra being used for relief of acute bronchospasm or status asthmaticus (must be No)
Dual monoclonal therapy: Fasenra being used as dual therapy with other monoclonal antibody treatments (must be No)

Prior Authorization

Submit completed PA form for Fasenra

Prescriber must submit the completed Fasenra prior authorization form including beneficiary, prescriber, and drug information and answer all clinical questions requested on the form.

Include beneficiary demographics and ID
Include prescriber NPI and requester contact information
Include drug name, strength, quantity, and length of therapy
Answer all clinical questions on the form (age, diagnosis, eosinophil counts, prior therapy, exacerbation history, FEV1, exclusions)

Continuation Therapy Criteria

Asthma: Continuation Therapy

Covered when ALL of the following are met:

Continuation criteria: Top-level: All continuation criteria must be met

Documentation of benefit: Documentation of continued clinical benefit from Fasenra

Evidence required: reductions in asthma exacerbations from baseline supported by medical records

Attach records: Medical records documenting beneficiary's current asthma status and response to Fasenra treatment are attached

Prescriber must attach medical records

Prescriber signature certifying accuracy of information

Signature mandatory

Documentation Required

Attach medical records for continuation

For continuation requests, attach medical records that document continued clinical benefit from Fasenra, including evidence of reductions in asthma exacerbations from baseline and the beneficiary's current asthma status. Prescriber signature is required on continuation requests.

Medical records showing reductions in exacerbations from baseline
Records documenting current asthma status and response to Fasenra
Prescriber signature and date (mandatory)

Exclusions / Use Limitations

Exclusions (must be NO)

Exclusions (must be NO): All of the following are exclusions and must be answered No

Prescriber must indicate No for each exclusion

Other eosinophilic conditions: Fasenra being used for treatment of other eosinophilic conditions (must be No)

Acute bronchospasm/status asthmaticus: Fasenra being used for relief of acute bronchospasm or status asthmaticus (must be No)

Dual monoclonal therapy: Fasenra being used as dual therapy with other monoclonal antibody treatments (must be No)

Denial Risk

Incomplete or missing evidence risk

Requests missing required evidence risk denial. Specifically, missing pre-treatment eosinophil counts, missing prior controller therapy history and duration, lack of documented exacerbation or hospitalization evidence, or absence of the prescriber signature may result in denial.

Pre-treatment serum or sputum eosinophil counts with dates
Documentation of prior controller therapy and duration (≥3 months high‑dose ICS + LABA)
Evidence of asthma exacerbations or hospitalizations in past 12 months
Prescriber signature certifying the request

Provider Actions / Prior Authorization Requirements

Prior Authorization

Submit completed PA form for Fasenra

Submit the completed Fasenra prior authorization form. The form must be fully completed with beneficiary, prescriber, and drug information and all clinical questions answered to request initiation of therapy.

Complete beneficiary demographics and ID fields
Provide prescriber NPI and contact details
Provide drug name, strength, quantity, and requested length of therapy
Answer all clinical eligibility questions (age, diagnosis, eosinophils, prior therapy, exacerbations, FEV1, exclusions)

Documentation Required

Attach medical records for continuation

Attach medical records for continuation requests demonstrating continued clinical benefit, specifically documentation of reductions in asthma exacerbations from baseline and the beneficiary's current asthma status and response to Fasenra.

Records showing fewer asthma exacerbations compared to baseline
Notes documenting current asthma control and response to treatment
Attach supporting documentation to the continuation request

Documentation Required

Provide laboratory and spirometry results

Provide required laboratory and spirometry results with the request: pre-treatment serum eosinophil counts (with date) or sputum eosinophil percentage as requested on the form, and prebronchodilator FEV1 value.

Pre-treatment eosinophil count ≥150 cells/mcL within 6 weeks or ≥300 cells/mcL within 12 months, or sputum eosinophils >3% (include date)
Prebronchodilator FEV1 value (document numeric value and indicate adult vs adolescent threshold)

Denial Risk

Incomplete or missing evidence risk

Incomplete or missing elements on the form may lead to denial. Required elements include eosinophil counts with dates, documentation of prior controller therapy and duration, evidence of exacerbations or hospitalizations, and the prescriber signature on continuation requests.

Pre-treatment eosinophil counts (and date) or sputum eosinophils >3%
Documentation of ≥3 months high‑dose inhaled corticosteroid + LABA prior therapy
Evidence of two or more exacerbations requiring systemic steroids or hospitalization in past 12 months
Prescriber signature certifying the accuracy of the request

Background & Definitions

Intended use: Fasenra (benralizumab) is intended as an add-on maintenance therapy for patients with severe eosinophilic asthma aged >= 12 years. The form requires documentation of a pre-treatment eosinophil threshold — ≥ 150 cells/mcL within 6 weeks or ≥ 300 cells/mcL within 12 months, or sputum eosinophils > 3%. Providers must document inadequate control after a minimum of 3 months of high‑dose inhaled corticosteroid plus long‑acting beta‑agonist, and a qualifying exacerbation history (e.g., two or more exacerbations requiring oral/systemic corticosteroids or a hospitalization in the prior 12 months). Prebronchodilator FEV1 must be provided (< 80% in adults; < 90% in adolescents). The prescriber must complete the form, attest to the diagnosis, sign the request, and attach medical records for continuation demonstrating clinical benefit.

Severe eosinophilic asthma: an asthma phenotype characterized by elevated eosinophil counts and recurrent exacerbations; the form requires the provider to assert the diagnosis.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFasenra (benralizumab) prior authorization form for severe eosinophilic asthma

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete the form and include beneficiary, prescriber, drug information, required labs/spirometry and attach medical records for continuation requests.

SourceLink

On This Page

OpenPayer

Fasenra (benralizumab) prior authorization form for severe eosinophilic asthma

Coverage Summary

Initial Therapy Criteria (New Authorization)

Continuation Therapy Criteria

Exclusions / Use Limitations

Applicable Codes

Provider Actions / Prior Authorization Requirements

Background & Definitions