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HealthPartners

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

Reslizumab (Cinqair) requires prior authorization from HealthPartners Pharmacy Administration. The setting of drug administration will be reviewed as part of the prior authorization.

Note:

For all inquiries, transfer to the Medical Injectable Line (ext 26135).

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
  7. For commercial products only (does not apply to Medicare or Minnesota Health Care Programs products), medication administration must occur at a clinic office or home-infusion setting unless medical necessity is met based on the criteria below, supported by medical documentation:
    1. The patient has experienced a severe or life-threatening reaction with previous infusions of the same or similar products; or,
    2. The patient has a medical condition that renders him or her unstable, exceptionally complex, immunocompromised or otherwise high-risk such that continued oversight in the current facility is required; or,
    3. There are no alternative settings available to the patient as a result of both of the following:
      1. The patient is unable to use home-infusion services as documented by the physician, social worker, or infusion provider; and,
      2. The patient is unable to access alternative settings due to unreasonable distance [>30 miles] or other extenuating circumstances.

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.

Setting: The type of physical site where the drug is provided. Settings include inpatient hospital, outpatient hospital, clinic office, or home-infusion.

  • Outpatient Hospital sites have physicians and practitioners on-site and are the appropriate site to manage unstable patients and patients experiencing certain moderate to severe adverse events. Hospital settings are typically the highest-cost, most-intensive, and are the highest level settings.
  • Clinic offices are lower level settings which are not outpatient hospital settings that can manage some unstable patients and patients experiencing adverse events. Physicians may or may not be readily available.
  • Home-infusion is a lower level setting, and is performed by a licensed nurse supported by a licensed pharmacy who have expertise in administering complex medications in a patient’s home. Home infusion providers regularly manage mild to moderate adverse events, and are prepared to manage severe adverse events if needed.

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
  • 01/01/2019 - Effective date
Review date
  • 02/2018
Revision date
  • 11/05/2018

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