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Coverage criteria policies

Benralizumab (Fasenra™) – 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

Benralizumab (Fasenra) 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 12 years of age or older; and,
  2. Has a diagnosis of  severe eosinophilic asthma with a documented blood eosinophil count of either:
    1. ≥150 cells/microliter at baseline or ≥ 300 cells/microliter in the past 12 months as documented in chart notes; and,
  3. Patient’s symptoms are not well controlled despite a 3 month adherent trial of high-dose inhaled corticosteroids in combination with a long-acting bronchodilator or leukotriene modifier; and ,
  4. Patient has had 2 or more exacerbations requiring treatment with systemic corticosteroids in the past 12 months; and,
  5. Fasenra must be used as an add-on to both high-dose inhaled corticosteroids and an additional controller medication (e.g., long-acting beta-agonist, etc.); and,
  6. Patient must not have concurrent use of Xolair, Nucala or Cinqair; and,
  7. At time of request, provide baseline FEV1 and frequency of asthma exacerbation per month

Initial authorizations are 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
  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)
    2. Improvement in lung function, measured in FEV1

Renewal authorizations are for 12 months in duration

Quantity limits:

Five injections (30mg/mL prefilled syringe) for the first 6 months

Six injections (30mg/mL prefilled syringe) for subsequent 12 months

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

C9466

Injection, benralizumab, 1 mg

J0517

Injection, benralizumab, 1 mg (effective 1/1/2019)

J3590

Unclassified biologics (use before 1/1/2019)

NDC

Codes

Description

00310173030

Fasenra 30 MG/ML SOSY

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/fasenra.jsp

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Policy activity

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

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