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Coverage criteria policies

Reslizumab (Cinqair®) – Minnesota Health Care Programs

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.

Coverage

All requests for doses exceeding the FDA-approved regimen will not be covered.

Initial Authorizations:
  1. Patient must be 18 years of age or older; and,
  2. Has a diagnosis of asthma with an eosinophilic phenotype indicated by blood eosinophil of ≥400 cells/mcL within 3 to 4 weeks of dosing (documentation of lab results must be submitted at time of request); and,
  3. Must be used for add-on maintenance treatment in patients with 6 months of claims history showing adherence with both of the following:
    1. High-dose inhaled corticosteroids
    2. An additional controller medication (e.g., long-acting beta agonist, etc.); and,
  4. Has evidence of severe disease indicated by all of the following:
    1. Asthmatic symptoms occurring throughout the day
    2. Frequent nighttime awakenings of 7 times per week
    3. Multiple doses of short-acting beta agonist (SABA) required daily for symptom control
    4. Extreme limitation of normal activities due to asthma symptoms
    5. Lung function (percent predicted FEV1) <60%
    6. More frequent and intense asthma exacerbations requiring oral systemic corticosteroids relative to mild or moderate asthma; and,
  5. Has uncontrolled disease documented by one of the following:
    1. At least one exacerbation in the previous year resulting in hospitalization or emergency department visits; or,
    2. Patient requires daily oral corticosteroids in addition to regular maintenance therapy; and,
  6. At time of request, provide baseline FEV1 and frequency of asthma exacerbation per month.

Initial approval will be for 6 months in duration

Reauthorizations:

  1. Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following:
    1. Parasitic (helminth) infection
    2. Herpes zoster infection
    3. Headache
    4. Injection site reaction
    5. Back pain
    6. Fatigue
  2. Treatment has resulted in clinical improvement as documented by at least one of the following:
    1. Decreased frequency of exacerbations (defined as improvement of asthma as demonstrated by decreased use of oral/systemic corticosteroids and/or less frequent hospitalizations and/or reduced frequency of ER visits); or,
    2. Improvement in lung function, measured in FEV1

Renewal approval will be for 12 months in duration.

Quantity limit:

One infusion (3 mg/kg) per 28 days.

Denial criteria:

Concurrent use with Xolair or Nucala.

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.

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:
HCPCS

Codes

Description

J9278

Injection, reslizumab, 1 mg

NDC

Codes

Description

59310061031

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. https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/cinqair.jsp

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Policy activity

  • 05/07/2018 - Date of origin
  • 10/01/2018 - Effective date

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