Last Review Date: 10/03/2022

Date of Origin: 12/12/2017

Dates Reviewed: 12/2017, 03/2018, 06/2018, 10/2018, 11/2019, 01/2020, 10/2020, 03/2021, 08/2021, 10/2022

1. Length of Authorization

Coverage is provided for 6 months may be renewed.

2. Dosing Limits

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

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

• Load: 30 billable units every 28 days for 3 doses
• Maintenance: 30 billable units every 56 days

3. Initial Approval Criteria ¹

Coverage is provided in the following conditions:

• Patient is at least 12 years of age; AND

Universal Criteria ¹

• Will not be used in combination with other anti-IgE, anti-IL4, or anti-IL5 monoclonal antibody (e.g., omalizumab, mepolizumab, reslizumab, dupilumab, 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

Severe Asthma † ^{1,2,5,7,8,9,11}

• Patient must have severe* disease; AND
• Patient must have asthma with an eosinophilic phenotype indicated by 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
• 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)

† FDA-approved indication(s); ‡ Compendia recommended indication(s); Ф Orphan Drug

4. Renewal Criteria ^1,7,8

• 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: parasitic (helminth) infection, severe hypersensitivity reactions (e.g., anaphylaxis, angioedema, urticaria, rash), etc.; AND

• Improvement in asthma symptoms or asthma exacerbations as evidenced by a 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)

5. Dosage/Administration ¹

6. 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

7. References

1. Fasenra [package insert]. Wilmington, DE; AstraZeneca Pharmaceuticals; February 2021.  Accessed August 2022.
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].

9. National Asthma Education and Prevention Program (NAEPP). 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Bethesda, MD: National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI); December 2020.
10. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2021 Update.  Available from: http://www.ginasthma.org. Accessed June 2021.
11. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2022 Update. Available from: http://www.ginasthma.org. Accessed August 2022.

Appendix 1 – Covered Diagnosis Codes

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.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