Skip to content
The Policy VaultThe Policy Vault

Fasenra pen — Blue Cross Blue Shield of Texas

severe eosinophilic asthma

Initial criteria

  • ONE of the following: A. The requested agent is eligible for continuation of therapy AND the prescriber states the patient has been treated with the requested agent (not on samples) within the past 90 days and is at risk if therapy is changed OR B. BOTH of the following:
  • For severe eosinophilic asthma: BOTH of the following: 1. Diagnosis confirmed by ONE of: baseline blood eosinophils ≥150 cells/µL while on high-dose inhaled corticosteroids or daily oral corticosteroids OR FeNO ≥20 parts per billion OR sputum eosinophils ≥2%; AND 2. History of uncontrolled asthma on asthma control therapy as shown by ONE of: ≥2 courses of systemic corticosteroids in past 12 months; or serious exacerbations requiring hospitalization, mechanical ventilation, ER/urgent care visits in past 12 months; or controlled asthma worsening with corticosteroid tapering; or baseline FEV1 <80% predicted.
  • For eosinophilic granulomatosis with polyangiitis (EGPA): ALL of the following: baseline eosinophils ≥1000 cells/µL OR ≥10% on differential count; history/presence of asthma; no severe organ- or life-threatening disease; and ONE of the following regarding OCS therapy: treated within past 90 days with oral corticosteroid for ≥4 weeks and will continue with requested agent OR intolerance/hypersensitivity to OCS OR contraindication to all OCS; and will use requested agent for relapsing/refractory disease, maintenance of remission, or disease control.
  • For hypereosinophilic syndrome (HES): ALL of the following: drug is FDA labeled or compendia supported for HES; diagnosis ≥6 months; confirmation by BOTH of: elevated eosinophil count ≥1000 cells/µL OR >20% marrow eosinophils OR tissue infiltration by eosinophils or deposition of granule proteins; and evaluation of organ involvement; no identifiable secondary cause; no FIP1L1-PDGFRA-positive disease; ≥2 HES flares in past 12 months; and ONE of the following: inadequate response to or intolerance/contraindication to OCS, hydroxyurea, interferon-a, or another immunosuppressant (e.g., cyclosporine, methotrexate).
  • For chronic rhinosinusitis with nasal polyps (CRSwNP): ALL of the following: drug is FDA labeled or compendia supported for CRSwNP; ≥2 CRS symptoms (nasal discharge, nasal obstruction/congestion, loss/decreased smell, facial pressure/pain); symptoms ≥12 consecutive weeks.