CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Fasenra 2413 A Sgm P2023

Defines coverage, documentation, prescriber specialty, initial and continuation authorization criteria, limitations, and concurrency restrictions for Fasenra (benralizumab) for members age 12 and older with severe asthma and an eosinophilic phenotype. Also lists required documentation for prior authorization and references.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFasenra 2413 A Sgm P2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit chart notes or medical records showing pretreatment blood eosinophil count and prior medication history for initial requests; for continuation submit chart notes documenting improved asthma control.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes for this policy.

12+Minimum covered age (years)

>=150Eosinophil threshold

6Initial auth (months)

12Continuation auth (months)

Coverage Summary

Fasenra (benralizumab) is indicated as an add-on maintenance treatment for severe asthma with an eosinophilic phenotype in patients aged 12 years and older. It is not indicated for treatment of other eosinophilic conditions or for relief of acute bronchospasm or status asthmaticus. Coverage is covered with criteria, requiring documentation of eosinophilia or steroid dependence and inadequate asthma control despite optimized inhaled and controller therapy.

Key thresholds and durations

Minimum covered age12+ years

Eosinophil thresholdBaseline blood eosinophil count >= 150 cells/µL

Initial authorization durationUp to 6 months

Continuation authorization durationUp to 12 months

Initial Approval (authorization up to 6 months)

Authorization of 6 months may be granted when criteria A or B below are met and all listed conditions apply:

Either

New or non-biologic prior biologic
- Prior biologic exposure: Member has previously received a biologic drug (e.g., Dupixent, Nucala) indicated for asthma
  If yes, authorization of 6 months may be granted
- Age: Member is 12 years of age or older
- Either baseline eosinophil or steroid dependence
  - Baseline blood eosinophil count: Member has a baseline blood eosinophil count of at least 150 cells per microliter>= 150 cells/µL
  - Systemic corticosteroid dependence: Member is dependent on systemic corticosteroids
- Evidence of uncontrolled asthma (at least one in past year)
  - Exacerbations - multiple: Two or more asthma exacerbations requiring oral or injectable corticosteroid treatment within the past year
  - Exacerbation - hospitalization/ED: One or more asthma exacerbation resulting in hospitalization or emergency medical care visit within the past year
  - Poor symptom control (frequent symptoms or reliever use, activity limited by asthma, night waking due to asthma)
- Optimized background therapy
  - High dose ICS: Inadequate asthma control despite current treatment with high dose inhaled corticosteroid
  - Additional controller: Inadequate asthma control despite current treatment with an additional controller (long acting beta2-agonist, long acting muscarinic antagonist, leukotriene modifier, or sustained-release theophylline)
- Maintenance therapy requirement: Member will continue to use maintenance asthma treatments (e.g., inhaled corticosteroid, additional controller) in combination with the requested medication
  Required for approval

ref": "b1_0"

title": "Initial Approval (authorization up to 6 months)" } , {

Exclusions / Not Medically Necessary

Denial Risk

Denial if criteria not met or excluded indication

Requests will be not medically necessary/denied for indications other than severe eosinophilic asthma in patients 12 years or older, for treatment of other eosinophilic conditions, or for acute bronchospasm/status asthmaticus.

Do not use concomitantly with any other biologic drug or targeted synthetic drug for the same indication; concomitant use may result in denial.

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization required with documentation

Submit chart notes or medical records showing pretreatment blood eosinophil count and prior medication history (drug, dose, frequency, duration) for initial requests; for continuation submit chart notes documenting improved asthma control.

Documentation Required

Prescriber specialty requirement

Medication must be prescribed by or in consultation with an allergist/immunologist or pulmonologist.

Billing Rule

Concomitant biologic prohibition

Do not use concomitantly with any other biologic drug or targeted synthetic drug for the same indication; concomitant use may result in denial.

Background

Fasenra (benralizumab) is indicated as an add-on maintenance treatment for patients aged 12 years and older with severe asthma and an eosinophilic phenotype. As an anti-eosinophil biologic, benralizumab is used in the eosinophilic phenotype context as add-on therapy for maintenance management of severe asthma. It is not for treatment of other eosinophilic conditions and not for relief of acute bronchospasm or status asthmaticus.