Fasenra Prior Authorization Criteria - Medicare Part D

Initial Evaluation

Fasenra will be approved when ALL of the following are met:

1. ONE of the following:
   1. The patient has a diagnosis of severe asthma with an eosinophilic phenotype AND BOTH of the following:
      1. The patient is at least 6 years of age
         AND
      2. The patient is currently being treated with AND will continue asthma control therapy (e.g., ICS, ICS/LABA, LTRA, LAMA, theophylline) in combination with the requested medication
         OR
   2. The patient has a diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) AND BOTH of the following:
      1. The patient is at least 18 years of age
         AND
      2. ONE of the following:
         1. The patient is currently being treated with a maximally tolerated oral corticosteroid
            OR
         2. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to an oral corticosteroid
            AND
2. The patient will NOT be using the requested medication in combination with Xolair, Dupixent, or with another injectable interleukin 5 (IL-5) inhibitor (e.g., Cinqair, Nucala) for the requested indication
   AND
3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., allergist, immunologist, pulmonologist, otolaryngologist, rheumatologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis 
   AND
4. The requested dose is within FDA labeled dosing for the requested indication

Length of approval: 12 months

Renewal Evaluation

Fasenra will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. ONE of the following:
   1. The patient has a diagnosis of severe asthma with an eosinophilic phenotype AND BOTH of the following:
      1. The patient is at least 6 years of age
         AND
      2. The patient is currently being treated with AND will continue asthma control therapy (e.g., ICS, ICS/LABA, LTRA, LAMA, theophylline) in combination with the requested medication
         OR
   2. The patient has a diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) AND BOTH of the following:
      1. The patient is at least 18 years of age
         AND
      2. ONE of the following:
         1. The patient is currently being treated with maintenance therapy with oral corticosteroid
            OR
         2. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to oral corticosteroid
            AND
3. The patient has had clinical benefit with the requested medication
   AND
4. The patient will NOT be using the requested medication in combination with Xolair, Dupixent, or with another injectable interleukin 5 (IL-5) inhibitor (e.g., Cinqair, Nucala) for the requested indication
   AND
5. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., allergist, immunologist, pulmonologist, otolaryngologist, rheumatologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
   AND
6. The requested dose is within the FDA labeled dosing for the requested indication

Length of approval: 12 months