benralizumab — CareFirst (Caremark)

Initial criteria

• Member is age ≥ 18 years
• Authorization of 12 months may be granted for members who have previously received a biologic drug (e.g., Nucala) indicated for EGPA in the past year
• Member has a history or presence of blood eosinophil count > 1000 cells per microliter OR eosinophil level > 10%
• Member is currently taking oral corticosteroids unless contraindicated or not tolerated
• Member has at least two of the following disease characteristics of EGPA: biopsy showing histopathological evidence of eosinophilic vasculitis/perivascular eosinophilic infiltration/eosinophil-rich granulomatous inflammation; neuropathy (mono or poly) with motor deficit or nerve conduction abnormality; non-fixed pulmonary infiltrates; sino-nasal abnormality; cardiomyopathy (by echocardiography or MRI); glomerulonephritis (hematuria, red cell casts, proteinuria); alveolar hemorrhage (by bronchoalveolar lavage); palpable purpura; ANCA positive (myeloperoxidase or proteinase 3)
• Member has had at least one relapse within 2 years prior to starting treatment (requiring increased oral corticosteroid dose, initiation or increased dose of immunosuppressive therapy, or hospitalization) OR has refractory disease

Reauthorization criteria

• Member is age ≥ 18 years
• Member has a beneficial response to treatment as demonstrated by any of the following: reduction in frequency of relapses, reduction or discontinuation of daily oral corticosteroid dose, or no active vasculitis

Approval duration

Initial: 12 months; Reauthorization: 12 months