BlueCross BlueShield of Tennessee Medical Policy Manual

Benralizumab

NDC CODE(S)

00310-1730-XX Fasenra 30 MG/ML SOSY (ASTRAZENECA)

DESCRIPTION

Benralizumab is a humanized alpha-directed cytolytic monoclonal antibody (IgG1, kappa) that directly binds to the alpha subunit of the human interleukin-5 receptor (IL-5Rα).   The IL-5 receptor is expressed on the surface of eosinophils and basophils.

By binding to the IL-5Rα chain, benralizumab reduces eosinophils through antibody-dependent cell-mediated cytotoxicity (ADCC).  A reduction in blood eosinophil counts was observed 24 hours post dosing; however the actual mechanism of benralizumab action in asthma has not been definitively established.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S)

DOSAGE & ADMINISTRATION

Severe asthma with eosinophilic phenotype

30 mg every 4 weeks for the first 3 doses, followed by once every 8 weeks thereafter.

LENGTH OF AUTHORIZATION

Coverage will be provided for a period of 6 months and may be renewed.

Click here to view DOSAGE LIMITS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION 

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

SOURCE

U. S. Food and Drug Administration. (2017, November). Center for Drug Evaluation and Research. Fasenra® (benralizumab) injection, for intravenous use. Retrieved December 5, 2017 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/761070s000lbl.pdf.

ORIGINAL EFFECTIVE DATE:  1/18/2018

MOST RECENT REVIEW DATE:  1/18/2018

ID_MRxEx

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.

 

 

DOSAGE LIMITS

Maximum billable units per dose and over time by indication as a Medical Benefit

Diagnosis

Billable Unit

Dosage

Severe asthma with eosinophilic phenotype

30 MG/1.0 ML

30 mg/month x 3 doses, then every 8 weeks with 6 month limit, renewable with criteria