CurrentNeighborhood Health Plan of Rhode IslandPolicy 2413-A

Fasenra (benralizumab)

Defines prior authorization, coverage criteria, documentation, prescriber specialty, and continuation requirements for Fasenra (benralizumab) for FDA-approved indications (severe eosinophilic asthma and EGPA) for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFasenra (benralizumab)

Policy CodePolicy 2413-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests with chart notes or medical record documentation showing pretreatment blood eosinophil count, prior medications tried, and for continuation, documentation of beneficial response or improved asthma control.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

2FDA-approved Indications Covered

6Min age (asthma)

18Min age (EGPA)

>=150/>1000Eosinophil thresholds (asthma/EGPA)

Coverage Summary

Defines prior authorization, coverage criteria, documentation, prescriber specialty, and continuation requirements for Fasenra (benralizumab) for Neighborhood Health Plan of Rhode Island members. Coverage: covered with criteria for FDA‑approved indications — add‑on maintenance treatment of severe eosinophilic asthma in patients aged 6 years and older and treatment of EGPA in adults aged 18 years and older. Not indicated for relief of acute bronchospasm or status asthmaticus. All other indications are considered investigational/experimental and not medically necessary.

Initial Therapy Criteria

Asthma - Initial Authorization (severe eosinophilic asthma)

Authorization of 6 months may be granted for members 6 years of age or older who have previously received a biologic drug indicated for asthma in the past year. Authorization of 6 months may be granted for treatment of severe asthma when ALL of the following criteria are met:

ALL of the following

Member is 6 years of age or older.
Member meets either of the following
- Member has a baseline blood eosinophil count of at least 150 cells per microliter.>= 150 cells per microliter
- Member is dependent on systemic corticosteroids.
Member has uncontrolled asthma as demonstrated by at least one of
- Two or more asthma exacerbations requiring oral or injectable corticosteroid treatment within the past year.
- One or more asthma exacerbation(s) resulting in hospitalization or emergency medical care visit(s) within the past year.
- Poor symptom control (frequent symptoms or reliever use, activity limited by asthma, night waking due to asthma) within the past year.
Inadequate control despite optimized background therapy
- Member has inadequate asthma control despite current treatment with both of the following medications at optimized doses:
- High-dose inhaled corticosteroid
- Additional controller (i.e., long-acting beta2-agonist, long-acting muscarinic antagonist, leukotriene modifier, or sustained-release theophylline)
Member will continue to use maintenance asthma treatments (i.e., inhaled corticosteroid and additional controller) in combination with the requested medication.

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EGPA (Eosinophilic Granulomatosis with Polyangiitis) - Initial Authorization

Authorization of 12 months may be granted for members 18 years of age or older when ALL of the following criteria are met:

ALL of the following

Member is 18 years of age or older.
Member has a history or presence of a blood eosinophil count of more than 1000 cells per microliter or a blood eosinophil level of greater than 10%.> 1000 cells per microliter OR > 10%
Member is currently taking oral corticosteroids, unless contraindicated or not tolerated.
Member has at least two of the following disease characteristics of EGPA
- Biopsy showing histopathological evidence of eosinophilic vasculitis, perivascular eosinophilic infiltration, or eosinophil-rich granulomatous inflammation

Continuation Therapy Criteria

Asthma - Continuation/Renewal Authorization

Authorization of 12 months may be granted for treatment of severe asthma when ALL of the following criteria are met:

ALL of the following

Member is 6 years of age or older.
Demonstrated improvement on requested medication
- A reduction in the frequency and/or severity of symptoms and exacerbations.
- A reduction in the daily maintenance oral corticosteroid dose.
Member will continue to use maintenance asthma treatments (i.e., inhaled corticosteroid and additional controller) in combination with the requested medication.

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EGPA - Continuation/ Renewal Authorization

Authorization of 12 months may be granted for continuation of treatment of EGPA when ALL of the following criteria are met:

ALL of the following

Member is 18 years of age or older.
Beneficial response to treatment demonstrated by any of
- A reduction in the frequency of relapses
- A reduction or discontinuation of daily oral corticosteroid dose
- No active vasculitis

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Provider Actions

Prior Authorization

Prior authorization required with documentation

Initial and continuation prior authorization requests must include chart notes or medical record documentation showing pretreatment blood eosinophil count (or percentage where applicable), systemic corticosteroid dependency if applicable, prior medications tried (drug, dose, frequency, duration). Continuation requests must also include documentation of beneficial response or improvement in asthma control.

Documentation Required

Prescriber specialty requirement for asthma

For the asthma indication, the medication must be prescribed by or in consultation with an allergist/immunologist or a pulmonologist.

Billing Rule

Concomitant biologic use prohibited

Member may not use the requested medication concomitantly with any other biologic drug or targeted synthetic drug for the same indication; claims may be denied if used concurrently.

P2025

Background

Fasenra (benralizumab) is an anti‑eosinophil biologic indicated as add‑on maintenance treatment for severe eosinophilic asthma in adult and pediatric patients aged 6 years and older, and for treatment of eosinophilic granulomatosis with polyangiitis (EGPA) in adults. It is not indicated for relief of acute bronchospasm or status asthmaticus. All other uses beyond FDA‑approved and specified compendial uses are considered investigational.

Eosinophilic granulomatosis with polyangiitis (EGPA)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyFasenra (benralizumab)

Policy CodePolicy 2413-A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Fasenra (benralizumab)

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Exclusions / Limitations

Applicable Codes

Provider Actions

Clinical Evidence

Background