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    v1.0.28
    OpenPayerPolicy UpdatesPulmonologyCommunity-Care Cinqair (reslizumab) Coverage | Ope…
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    CurrentCommunity-CarePolicy N/A

    Cinqair (reslizumab) Medical Benefit Medication Utilization Policy

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    Defines medical-coverage criteria, quantity limits, authorization periods, and applicable billing codes for reslizumab (Cinqair) when used to treat eosinophilic severe asthma in adults under the medical benefit.

    Policy Summary
    PayerCommunity-Care
    PolicyCinqair (reslizumab) Medical Benefit Medication Utilization Policy
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewOct 1, 2024
    Next Review DateOct 1, 2024
    Key ActionObtain prior authorization documenting age ≥18, specialist prescriber, baseline eosinophils ≥150 cells/µL, and history of ≥2 exacerbations despite controller adherence.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≥18Minimum age for initial approval
    ≥150Baseline eosinophil threshold
    ≥2Exacerbations required (yr)
    6 vials/28d

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Quantity limit
    J2786HCPCS

    Coverage Criteria for Reslizumab (Cinqair)

    Initial Therapy — Covered when ALL of the following are met

    Covered when ALL of the following are met

    Initial approval criteria: Patient is ≥ 18 years of age.
    Prescribed by, or in consultation with, an allergist, pulmonologist, or immunologist.
    Diagnosis of severe asthma.
    Diagnosis of eosinophilic asthma with a provided baseline blood eosinophil concentration ≥ 150 cells/µL.
    History of ≥ 2 asthma exacerbations requiring treatment with systemic corticosteroids or emergency department visit or hospitalization for treatment of asthma within the past year despite adherent utilization of either an inhaled corticosteroid (ICS) with 1 additional asthma controller medication or maximally tolerated inhaled corticosteroid/long-acting beta agonist (ICS/LABA) combination product.
    Prescriber attestation: Prescriber attests to both: 1) patient adherence to controller medications; and 2) reslizumab will not be used in combination with another targeted immunomodulator product used for asthma.
    Quantity and administration: If approved, reslizumab will be authorized for a quantity of 6 vials per 28 days (1 vial = 100 mg); a weight is required for approval.

    Continuation Therapy — Covered when ALL of the following are met

    Covered when ALL of the following are met

    Continuation criteria: Diagnosis of eosinophilic asthma remains present.
    A positive clinical response to reslizumab has been achieved.
    Reslizumab will not be used in combination with another targeted immunomodulator product used for asthma (prescriber attestation).

    Per policy, prescriber attestation is required that reslizumab will not be used in combination with another targeted immunomodulator product for asthma. The prescriber must also attest to the patient’s adherence to controller medications as a condition of initial approval. Additionally, this policy limits initial use to adults; patients must be ≥ 18 years for initial authorization. Specialist involvement is required — the drug must be prescribed by, or in consultation with, an allergist, pulmonologist, or immunologist.

    This therapy is not covered for patients who do not meet the specified clinical entry criteria. Specifically, treatment is not medically necessary for individuals who are younger than 18 years, who do not have a diagnosis of severe asthma with an eosinophilic phenotype, who have a baseline blood eosinophil concentration below 150 cells/µL, or who do not have a documented history of ≥ 2 asthma exacerbations in the prior year despite adherent use of an ICS plus an additional controller or maximized ICS/LABA. Use is also not covered when the prescriber does not attest that reslizumab will not be given concurrently with another targeted asthma immunomodulator.

    Billing and Diagnostic Codes

    Applicable HCPCS CodesHCPCSCovered
    J2786Injection, reslizumab, 1 mg
    inv-06: Baseline blood eosinophil concentration
    Required baseline blood eosinophil concentration≥ 150 cells/µL
    Measurement contextBaseline blood eosinophil concentration must be provided with the initial request
    Use for continuityOngoing diagnosis of eosinophilic asthma for continuation references this threshold
    inv-07: Asthma exacerbation history
    Required exacerbation count (prior 12 months)≥ 2 asthma exacerbations
    Exacerbation definitionExacerbations requiring systemic corticosteroids or an ED visit or hospitalization for asthma
    Context of controller therapy

    Provider Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required before initiation of reslizumab (Cinqair). Documentation must demonstrate that the patient meets the high-level initial approval criteria including age (≥ 18 years), specialty of prescriber (allergist, pulmonologist, or immunologist), diagnosis of severe eosinophilic asthma, baseline blood eosinophil concentration ≥ 150 cells/µL, weight (for dosing), and history of exacerbations despite adherent controller therapy.

    • Required for initial and continuation therapy
    • Authorization periods: initial = 6 months; continuation = 1 year
    Step Therapy

    Step-Therapy Requirement

    Step therapy expectations: patient must have had ≥ 2 asthma exacerbations in the past 12 months requiring systemic corticosteroids, ED visit, or hospitalization despite adherent use of an inhaled corticosteroid (ICS) plus at least one additional controller medication or maximally tolerated ICS/LABA combination.

    • Exacerbations must have occurred despite adherent use of ICS + additional controller(s)

    Background

    Reslizumab (Cinqair) is an anti–IL‑5 monoclonal antibody indicated for patients with eosinophilic severe asthma. The policy restricts use to adults with documented eosinophilic asthma — defined in this policy by a baseline blood eosinophil concentration of at least 150 cells/µL — and requires a history of treatment-refractory exacerbations despite controller therapy (≥ 2 exacerbations in the past year). Because the evidence and the FDA‑labeled indication support adult use in this context, the policy limits initial approval to patients ≥ 18 years and mandates specialist involvement and prescriber attestation that reslizumab will not be combined with another targeted immunomodulator for asthma.

    Key Definitions

    inv-13: Eosinophilic asthma
    DefinitionEosinophilic asthma is defined by a baseline blood eosinophil concentration ≥ 150 cells/µL
    Documented at initial requestBaseline eosinophil concentration must be provided with the initial authorization request
    Role in coverageRequired criterion for both initial approval and continuation of therapy
    inv-14: Severe asthma (policy context)
    Exacerbation threshold≥ 2 exacerbations in the past year requiring systemic corticosteroids or ED visit/hospitalization
    Therapy contextExacerbations must have occurred despite adherent use of an inhaled corticosteroid plus one additional controller or maximized ICS/LABA
    Policy Summary
    PayerCommunity-Care
    PolicyCinqair (reslizumab) Medical Benefit Medication Utilization Policy
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewOct 1, 2024
    Next Review DateOct 1, 2024
    Key ActionObtain prior authorization documenting age ≥18, specialist prescriber, baseline eosinophils ≥150 cells/µL, and history of ≥2 exacerbations despite controller adherence.
    SourceLink
    On This Page
    Coverage Criteria for Reslizumab (Cinqair)Billing and Diagnostic CodesProvider Authorization and Documentation RequirementsBackgroundKey Definitions
    Occurrences must be within the past year despite adherent use of ICS plus one additional controller or maximized ICS/LABA
  1. Prescriber must attest to patient adherence to controller medications
    2. Documentation Required

    Required Documentation for Review

    Provide the following documentation with the prior authorization request so the clinical review can be completed:

    • Patient age (must be ≥ 18 years)
    • Prescriber specialty (allergist, pulmonologist, or immunologist) or documentation of consultation
    • Diagnosis (severe asthma with eosinophilic phenotype)
    • Baseline blood eosinophil concentration (≥ 150 cells/µL) and date of result
    • Weight (required for dosing)
    • Exacerbation history (≥ 2 in past 12 months with systemic corticosteroids, ED visit, or hospitalization)
    • Prior and current controller therapies, evidence of adherent use of ICS + ≥1 additional controller or maximally tolerated ICS/LABA
    • Prescriber attestation that reslizumab will not be used in combination with another targeted immunomodulator for asthma
    Denial Risk

    Triggers for Potential Denial

    Requests may be denied if submitted documentation fails to meet required criteria or is incomplete.

    • Patient age < 18 years
    • Prescriber is not an allergist, pulmonologist, or immunologist and no consultation is provided
    • Diagnosis does not support severe eosinophilic asthma
    • Baseline eosinophil count not provided or < 150 cells/µL
    • Weight not provided
    • Insufficient exacerbation history (fewer than 2 qualifying events in the past year)
    • No evidence of adherent use of required controller therapy (ICS + additional controller or maximally tolerated ICS/LABA)
    • Concurrent use of another targeted immunomodulator for asthma
    Relation to severe asthma diagnosis
    This exacerbation history, combined with controller adherence failure, constitutes the policy's definition of severe asthma for coverage determination