Outpatient Medical Injectable Monoclonal Antibodies for the Treatment of Asthma and Eosinophilic Conditions Request Form
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Request form and documentation requirements for outpatient medical benefit coverage of monoclonal antibody injectables (e.g., Fasenra, Nucala, Cinqair, Tezspire) for asthma and eosinophilic conditions; intended for ordering providers and facility staff to request prior authorization or medical review.
No material clinical or coverage changes in this revision.
Coverage Criteria and Indications
Initial and continuation documentation elements for asthma
Covered when the requester provides the following documentation elements for initial or continuation authorization for asthma.
These items are requested on the form to support medical necessity determination.
The form specifically asks whether the member has FIP1L1-PDGFRα kinase–positive HES. A positive result identifies a distinct molecular subtype of hypereosinophilic syndrome and would direct evaluation toward targeted therapies for that mutation rather than standard Nucala eligibility; therefore the presence or absence of this kinase–positive status is queried as part of the eligibility assessment for Nucala.
Coding and Clinical Measures
Provider Submission Requirements and Actions
Prior Authorization Required
Prior Authorization Required — complete the request form and fax to the specified number. Include HCPCS/J-code examples when applicable and confirm this is a Medical Benefit request.
- Fax completed form to 833-619-5745
- Indicate whether supply is via specialty pharmacy or Buy & Bill
- Include Date of Service and Facility information as applicable
- Include ICD-10 diagnosis code(s)
Document Prior Biologic Trials and Combination Use
Document prior biologic trials, responses, contraindications, and whether combination therapy is planned. Indicate if the request is for a new start or continuation of therapy.
- List prior biologic therapies tried and whether the member failed or had contraindications
- Provide dates, doses, and clinical response for prior biologics (improvement, no improvement, adverse events)
- Indicate if the requested product will be used as add-on maintenance and/or in combination with other biologics
- Specify New Start vs Continuation of Therapy
Required Documentation to Accompany Request
Required documentation must accompany the request form. Provide complete member identifiers, provider and facility information, ICD‑10 code(s), date(s) of service, relevant labs, clinical notes, objective measures, and attachment of prior treatment history.
- Member identifiers: name, DOB, UMI/Member ID
- Provider and facility: requesting physician name, NPI, address, office contact, facility name and NPI
- Clinical information: ICD‑10 diagnosis code(s); indication (e.g., severe uncontrolled asthma, CRSwNP)
- Objective measures: ACT/ACQ scores, number of exacerbations in past 12 months, pre‑bronchodilator FEV1 with date, blood eosinophil count with date
- Treatment history: list of medications (name, dose, duration) over the past year; prior biologics tried/failed; response to prior therapy
- Attachments: pertinent clinical notes, test results, imaging/endoscopy reports, and documentation of inadequate response to prior therapies (e.g., nasal corticosteroids for CRSwNP)
Form Completion and Documentation
Form completion and supporting documentation must be thorough. Incomplete fields or missing attachments (labs, prior treatment records, objective measures) may delay review or result in denial. Ensure all required fields on the form are completed and all pertinent clinical information is attached before faxing.
- Do not leave required form fields blank (member identifiers, NPI, ICD‑10, dates)
- Attach supporting clinical notes, lab values (e.g., eosinophil count), ACT/ACQ scores, FEV1 results, and prior biologic trial documentation
- Indicate clearly whether request is New Start or Continuation of Therapy
- Missing or incomplete documentation may result in delayed processing or denial
Definitions and Clinical Thresholds
Background and Scope
This request form supports use of monoclonal antibodies as add-on maintenance therapy for severe or uncontrolled asthma and for specific eosinophilic conditions, including Hypereosinophilic Syndrome (HES). The HES section of the form collects indication-specific items such as duration of diagnosis (≥6 months), exclusion of secondary causes, molecular testing (FIP1L1-PDGFRα kinase status), number of recent flares, baseline blood eosinophil count, and stability on current HES therapy prior to initiating therapy with Nucala.
Revision History
Outpatient Medical Injectable Monoclonal Antibodies request form for asthma and eosinophilic conditions published for use; includes fax submission instructions (Fax to 833-619-5745) and fields for member/provider identifiers and service date.
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