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Coverage criteria policies

Reslizumab (Cinqair®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Cinqair® requires prior authorization from Pharmacy Administration.

Coverage

Reslizumab (Cinqair) is reserved for patients meeting all of the following:

Severe Asthma:

  1. Patient is followed by an asthma specialist, allergist, or pulmonologist, and
  2. Prescribed within an FDA-approved dosing regimen; and
  3. Patient is 18 years and older with a pre-treatment serum eosinophil count of 400 cells/mcL or greater at screening (within previous 4 weeks of request), and
  4. Patient has poor asthma control (see criteria #5) despite the following standard therapies:
  5. Regular use of high-dose inhaled steroids (such as Flovent); and
    1. Regular or periodic use of oral steroids; and
    2. Regular use of a long-acting beta-agonist (such as Serevent)
  6. Inadequate asthma control despite standard therapies is defined as one of the following:
    1. At least 2 exacerbations requiring oral systemic corticosteroids in the last 12 months,
    2. At least 1 exacerbation treated in hospital or requiring mechanical ventilation in the last 12 months

All authorizations will be for one year. Renewals will be provided annually with documentation that the medication is effective.

Definitions

Cinqair is an interleukin-5 antagonist monoclonal antibody (IgG4 kappa) indicated for add-on maintenance treatment of patients with severe asthma aged 18 years and older, and with an eosinophilic phenotype.

Limitation of use:

  • Cinqair is not indicated for treatment of other eosinophilic conditions.
  • Cinqair is not indicated for the relief of acute bronchospasm or status asthmaticus.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:
HCPC Codes

Codes

Description

J2786

Injection, reslizumab, 1 mg

NDC Codes

Codes

Description

59310-0610-31

Cinqair 100 MG/10ML SOLN

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Cinqair Prescribing Information. Frazer, PA. Teva Respiratory, LLC, May 2016.

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Policy activity

  • 08/01/2016 - Date of origin
  • 05/02/2017 - Effective date
Review date
  • 02/2018
Revision date
  • 02/06/2017

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