CurrentUnitedHealthcarePolicy N/A

Fasenra (benralizumab) prior authorization for severe eosinophilic asthma

This document is a prior authorization/clinical request form for prescribing Fasenra (benralizumab) for treatment of severe eosinophilic asthma and continuation requests; it is completed by the prescribing provider for UnitedHealthcare beneficiaries.

Policy Summary

PayerUnitedHealthcare

PolicyFasenra (benralizumab) prior authorization for severe eosinophilic asthma

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete the beneficiary, prescriber, and drug sections of the prior authorization form, attach medical records, and sign the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age ≥ 12minimum beneficiary age

≥150 / ≥300eosinophil thresholds

≥3 monthsprior controller trial

≥2 in 12 moexacerbation requirement

Coverage Criteria for Fasenra (benralizumab)

New Therapy — Coverage Criteria

Covered when ALL of the following are met:

Age: Beneficiary is age 12 or greaterage >= 12

see chunk 3

Diagnosis of severe eosinophilic asthma

see chunk 3

Eosinophil count: Pre-treatment serum eosinophil count >=150 cells/mcL within the past 6 weeks OR >=300 cells/mcL within the past 12 months OR sputum eosinophils >3%>=150 cells/mcL (screening) or >=300 cells/mcL (12 months)

see chunk 3

Policy Summary

PayerUnitedHealthcare

PolicyFasenra (benralizumab) prior authorization for severe eosinophilic asthma

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete the beneficiary, prescriber, and drug sections of the prior authorization form, attach medical records, and sign the form.

SourceLink

On This Page

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Continuation Therapy — Coverage Criteria

Covered for continuation when ALL of the following are met:

Clinical benefit: Beneficiary has experienced continued clinical benefit as evidenced by reductions in asthma exacerbations from baseline supported by medical recordsdocumented reduction in exacerbations

attach medical records; see chunk 4

Documentation: Medical records documenting current asthma status and response to Fasenra are attached; prescriber signature is provided on the request

see chunk 4

Fasenra (benralizumab) is not indicated for relief of acute bronchospasm or status asthmaticus. The prior authorization form explicitly asks whether Fasenra is being used for acute bronchospasm or status asthmaticus, and requests will not meet the new-therapy coverage criteria when used for these acute indications. Additionally, Fasenra should not be used for other eosinophilic conditions unless the specific condition and indication are appropriate and documented on the request. Requests that propose concurrent use of Fasenra as dual therapy with other monoclonal antibody treatments for asthma are also excluded from coverage under the new-therapy criteria.

Clinical Thresholds and Key Eligibility Metrics

Pre‑treatment eosinophil count — thresholds

Screening serum eosinophils≥150 cells/mcL within the past 6 weeks (screening)

Historical serum eosinophils≥300 cells/mcL within the past 12 months

Alternative sputum criterionSputum eosinophils >3%

Minimum prior controller therapy duration

Required regimenHigh‑dose inhaled corticosteroid in combination with a long‑acting beta‑agonist

Minimum durationAt least 3 months of the high‑dose ICS + LABA regimen

PurposeDocumented inadequate control after the trial is required before initiation

Exacerbation history

Exacerbation count thresholdTwo or more asthma exacerbations in the past 12 months

Exacerbation definitionExacerbations requiring oral or systemic corticosteroids or resulting in hospitalization

DocumentationList details of exacerbations and dates on the form

Minimum age

Minimum age for therapy initiationAge 12 years or greater

VerificationForm asks: 'Is the beneficiary age 12 or greater?' with yes/no response

ApplicabilityApplies to new therapy requests (age requirement included in coverage criteria)

Provider Requirements and Submission Instructions

Prior Authorization

Prior authorization form completion — provider must complete all sections

Complete the prior authorization form entirely: include beneficiary, prescriber, and drug information, and answer all therapy-specific sections for either new or continuation therapy requests.

Provide beneficiary name, ID, DOB, and gender (fields 1–5).
Provide prescriber NPI and requester contact (fields 6–7).
Provide drug name, strength, quantity per 30 days, and requested length of therapy (fields 8–11).
Answer all asthma-specific screening questions for new therapy (section: Asthma: New Therapy).
For continuation requests, complete Asthma: Continuation Therapy questions 1–11 and attach supporting records.

Step Therapy

Required prior controller therapy — minimum 3-month high-dose ICS + LABA trial

Prior controller therapy must be documented. Requests for Fasenra require demonstration of inadequate control after an adequate trial of high-dose inhaled corticosteroid (ICS) plus a long-acting beta-agonist (LABA).

Document a minimum 3-month trial of high-dose ICS in combination with a LABA and indicate inadequate control (Asthma: New Therapy question 4).
Include details of prior controller medications, doses, and dates of therapy in the submitted medical records.

Documentation Required

Required documentation — attach medical records; prescriber signature mandatory

Attach medical records showing current asthma status and objective response to therapy. Prescriber signature is required on continuation requests.

Attach records documenting eosinophil counts, FEV1 values, and exacerbation history as applicable.
For continuation requests, include documentation of reduced exacerbations from baseline consistent with clinical benefit (Asthma: Continuation Therapy question 11).
Prescriber signature and date are mandatory on continuation requests.

Denial Risk

Potential denial triggers — common documentation and eligibility issues

Common reasons for denial — confirm eligibility criteria and documentation before submission to avoid delays or denial.

Age criteria not met (beneficiary must be age 12 or greater for Fasenra; Asthma: New Therapy question 1).
Eosinophil thresholds not documented or below required levels (pre-treatment serum eosinophil <150 cells/mcL within 6 weeks or <300 cells/mcL within 12 months when required; Asthma: New Therapy question 3).
No documented inadequate control after a minimum 3-month trial of high-dose ICS + LABA (Asthma: New Therapy question 4).
Insufficient exacerbation history (fewer than two exacerbations requiring systemic corticosteroids or hospitalization in past 12 months; Asthma: New Therapy question 5).
Missing objective measures (prebronchodilator FEV1 not documented when required) or missing attachments of medical records.
Use for excluded indications (e.g., acute bronchospasm/status asthmaticus, dual monoclonal antibody therapy, or other eosinophilic conditions without documentation).

Background on Fasenra (benralizumab)

Fasenra (benralizumab) is intended as an add-on maintenance therapy for patients with severe eosinophilic asthma age 12 years or older. The form defines clinical eligibility by objective and historical measures including pre-treatment eosinophil thresholds, inadequate control despite optimized inhaled therapy, exacerbation history, and lung function. Specifically, eligibility assessment requires documentation of a pre-treatment serum eosinophil count of ≥150 cells/mcL within six weeks or ≥300 cells/mcL within the prior 12 months (or sputum eosinophils >3%), evidence of inadequate control after at least a 3-month trial of high‑dose inhaled corticosteroid plus a long‑acting beta‑agonist, and a history of two or more exacerbations requiring systemic/oral corticosteroids or hospitalization in the past 12 months. The form also asks whether Fasenra is being used as add‑on maintenance therapy to ensure use is for chronic management rather than acute relief.

OpenPayer

Fasenra (benralizumab) prior authorization for severe eosinophilic asthma

Coverage Criteria for Fasenra (benralizumab)

Clinical Thresholds and Key Eligibility Metrics

Provider Requirements and Submission Instructions

Background on Fasenra (benralizumab)

Definitions