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Fasenra pen — Blue Cross Blue Shield of Illinois

chronic rhinosinusitis with nasal polyps (CRSwNP)

Initial criteria

  • For continuation of therapy: prescriber states the patient has been treated with the requested agent (not starting on samples) within the past 90 days AND is at risk if therapy is changed
  • For severe eosinophilic asthma: BOTH of the following must be met:
  • • Diagnosis confirmed by ONE of: (a) baseline blood eosinophil count ≥150 cells/microliter while on high-dose inhaled or daily oral corticosteroids OR (b) fraction of exhaled nitric oxide (FeNO) ≥20 ppb while on high-dose inhaled or daily oral corticosteroids OR (c) sputum eosinophils ≥2% while on high-dose inhaled or daily oral corticosteroids
  • • History of uncontrolled asthma on asthma control therapy demonstrated by ONE of: (a) ≥2 steroid bursts in past 12 months OR (b) ≥1 serious asthma exacerbation requiring hospitalization/mechanical ventilation/ED or urgent care visit in past 12 months OR (c) controlled asthma that worsens with tapering of corticosteroids OR (d) baseline FEV1 <80% predicted
  • For eosinophilic granulomatosis with polyangiitis (EGPA): ALL of the following must be met:
  • • Baseline blood eosinophilia ≥1000 cells/microliter OR eosinophil level ≥10% on WBC differential
  • • History or presence of asthma
  • • No severe disease with organ- or life-threatening manifestations (e.g., alveolar hemorrhage, glomerulonephritis, CNS vasculitis, mononeuritis multiplex, cardiac involvement, mesenteric ischemia, limb/digit ischemia)
  • • ONE of: (a) currently treated within past 90 days with oral corticosteroid for ≥4 weeks AND will use oral corticosteroid with requested agent OR (b) intolerance or hypersensitivity to oral corticosteroid therapy OR (c) FDA labeled contraindication to all oral corticosteroids
  • • Will use requested agent for ONE of: (a) relapsing or refractory disease OR (b) maintenance of disease remission
  • For hypereosinophilic syndrome (HES): ALL of the following must be met:
  • • Requested agent is FDA labeled or compendia supported for HES
  • • Diagnosis of HES for ≥6 months
  • • Diagnosis confirmed by BOTH: (a) ONE of: peripheral blood eosinophil count ≥1000 cells/microliter OR eosinophils in bone marrow >20% OR marked eosinophil granule deposition OR extensive tissue eosinophil infiltration; AND (b) evaluation of hypereosinophilia-related organ involvement
  • • No identifiable secondary cause of HES (e.g., infection, allergy/atopy, medications, collagen vascular disease, metabolic, solid tumor/lymphoma)
  • • No FIP1L1-PDGFRA-positive disease
  • • At least 2 HES flares within past 12 months requiring escalation in therapy
  • • ONE of: (a) inadequate response to oral corticosteroid, hydroxyurea, interferon-a, or other immunosuppressive agent (e.g., cyclosporine, methotrexate) OR (b) intolerance or hypersensitivity to those agents OR (c) FDA labeled contraindication to hydroxyurea, interferon-a, and all oral corticosteroids and immunosuppressants used for HES
  • For chronic rhinosinusitis with nasal polyps (CRSwNP): ALL of the following must be met:
  • • Requested agent is FDA labeled or compendia supported for CRSwNP
  • • Patient has at least TWO symptoms consistent with chronic rhinosinusitis (nasal discharge, nasal obstruction/congestion, loss/decreased smell, facial pressure/pain)
  • • Symptoms consistent with chronic rhinosinusitis for ≥12 consecutive weeks