ph-0347
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Fasenra® (benralizumab)

Policy Number: PH-0347

 

Subcutaneous

 

Last Review Date: 03/01/2021

Date of Origin: 12/12/2017

Dates Reviewed: 12/2017, 03/2018, 06/2018, 10/2018, 11/2019, 01/2020, 10/2020, 03/2021

 

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

 

  1. Length of Authorization

Coverage is provided for six months and is eligible for renewal.

  1. Dosing Limits

A.  Quantity Limit (max daily dose) [NDC Unit]:

  • 30 mg single dose prefilled syringe
    • Load: 1 syringe every 28 days for 3 doses
    • Maintenance: 1 syringe every 56 days
  • 30 mg single dose autoinjector Fasenra Pen
    • Load: 1 autoinjector every 28 days for 3 doses
    • Maintenance: 1 autoinjector every 56 days

B.  Max Units (per dose and over time) [HCPCS Unit]:

    Severe Asthma with an eosinophilic phenotype

    • Load: 30 billable units every 28 days for 3 doses
    • Maintenance: 30 billable units every 56 days
  1. Initial Approval Criteria

Coverage is provided in the following conditions:

Universal Criteria 1

  • Must not be used in combination with another monoclonal antibody (e.g., omalizumab mepolizumab, reslizumab, etc.); AND

Severe Asthma † 1-8

  • Patient is at least 12 years of age; AND
  • Patient must have severe* disease; AND
  • Patient must have asthma with an eosinophilic phenotype defined as blood eosinophils ≥150 cells/µL within 6 weeks of dosing; AND
  • Must be used for add-on maintenance treatment in patients regularly receiving BOTH of the following:
    • Medium to high-dose inhaled corticosteroids; AND
    • An additional controller medication (e.g., long-acting beta agonist, leukotriene modifiers, etc.); AND
  • Must NOT be used for either of the following:
    • Treatment of other eosinophilic conditions (e.g., allergic bronchopulmonary aspergillosis/mycosis, Churg-Strauss syndrome, hypereosinophilic syndrome, etc.)
    • Relief of acute bronchospasm or status asthmaticus; AND
  • Patient must have two or more exacerbations in the previous year requiring daily oral corticosteroids for at least 3 days (in addition to the regular maintenance therapy defined above); AND
  • Baseline measurement of at least one of the following for assessment of clinical status:
    • Use of systemic corticosteroids
    • Use of inhaled corticosteroids
    • Number of hospitalizations, ER visits, or unscheduled visits to healthcare provider due to condition
    • Forced expiratory volume in 1 second (FEV1)

*Components of severity for classifying asthma as severe may include any of the following (not all inclusive):

  • Symptoms throughout the day
  • Nighttime awakenings, often 7x/week
  • SABA use for symptom control occurs several times per day
  • Extremely limited normal activities
  • Lung function (percent predicted FEV1) <60%
  • Exacerbations requiring oral systemic corticosteroids are generally more frequent and intense relative to moderate asthma

FDA-approved indication(s)

  1. Renewal Criteria 1-3,7
  • Patient continues to meet the universal and other indication-specific relevant criteria identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: parasitic (helminth) infection, severe hypersensitivity reactions, etc.; AND
  • Improvement in asthma symptoms or asthma exacerbations as evidenced by decrease in one or more of the following:
    • Use of systemic corticosteroids
    • Two-fold or greater decrease in inhaled corticosteroid use for at least 3 days
    • Hospitalizations
    • ER visits
    • Unscheduled visits to healthcare provider; OR
  • Improvement from baseline in forced expiratory volume in 1 second (FEV1)
  1. Dosage/Administration

Indication

Dose

Severe Asthma with eosinophilic phenotype

30 mg administered subcutaneously every 4 weeks for the first three doses and then once every 8 weeks thereafter.

  1. Billing Code/Availability Information

HCPCS Code:

  • J0517 - Injection, benralizumab, 1 mg: 1 billable unit = 1 mg

NDC:

  • Fasenra 30 mg/mL single dose prefilled syringe: 00310-1730-xx
  • Fasenra 30 mg/mL single dose autoinjector FASENRA PEN: 00310-1830-xx
  1. References
  1. Fasenra [package insert]. Wilmington, DE; AstraZeneca Pharmaceuticals; October 2019.  Accessed September 2020.
  2. National Asthma Education and Prevention Program (NAEPP). Guidelines for the diagnosis and management of asthma. Expert Panel Report 3. Bethesda, MD: National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI); August 2007.
  3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2019 Update.  Available from: http://www.ginasthma.org. Accessed September 2020.
  4. Walford HH, Doherty TA. Diagnosis and management of eosinophilic asthma: a US perspective. J Asthma Allergy. 2014; 7: 53–65.
  5. Goldman M, Hirsch I, Zangrilli JG, et al. The association between blood eosinophil count and benralizumab efficacy for patients with severe, uncontrolled asthma: subanalyses of the Phase III SIROCCO and CALIMA studies. Curr Med Res Opin. 2017 Sep;33(9):1605-1613. doi: 10.1080/03007995.2017.1347091. Epub 2017 Jul 19.
  6. The Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2017. Available from: www.ginasthma.org.
  7. Chung KF, Wenzel SE, Brozek JL, et al.  International ERS/ATS Guidelines on Definition, Evaluation, and Treatment of Severe Asthma. Eur Respir J 2014; 43: 343-373.
  8. Holguin F, Cardet JC, Chung KF, et al. Management of severe asthma: a European

Respiratory Society/American Thoracic Society guideline. Eur Respir J 2020; 55: 1900588 [https://doi.org/10.1183/13993003.00588-2019].

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

J45.50

Severe persistent asthma, uncomplicated

J45.51

Severe persistent asthma with (acute) exacerbation

J45.52

Severe persistent asthma with status asthmaticus

J82.81

Eosinophilic pneumonia, NOS

J82.82

Acute eosinophilic pneumonia

J82.83

Eosinophilic asthma

J82.89

Other pulmonary eosinophilia, not elsewhere classified

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

FASENRA® (benralizumab) Prior Auth Criteria
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