Fasenra (benralizumab) Pen (autoinjector) — Point32Health
Eosinophilic granulomatosis with polyangiitis (EGPA)
Initial criteria
- Documented diagnosis of eosinophilic granulomatosis with polyangiitis
- Documentation the patient has at least two (2) of the following disease characteristics of eosinophilic granulomatosis with polyangiitis: (a) Alveolar hemorrhage (by bronchoalveolar lavage) OR (b) Anti-neutrophil cytoplasmic antibody (ANCA) positive (Myeloperoxidase or proteinease 3) OR (c) Asthma OR (d) Biopsy containing a blood vessel with extravascular eosinophils OR (e) Cardiomyopathy (established by echocardiography or magnetic resonance imaging) OR (f) Eosinophilia (at least 10% eosinophils on the differential leukocyte count) OR (g) Glomerulonephritis (hematuria, red cell casts, proteinuria) OR (h) Migratory or transient pulmonary infiltrates on chest x-rays OR (i) Neuropathy, mono or poly (motor deficit or nerve conduction abnormality) OR (j) Palpable purpura OR (k) Paranasal sinus abnormalities
- Patient age ≥ 18 years
- Prescribed by or in consultation with an allergist, immunologist, pulmonologist, or rheumatologist
- Documentation of one (1) of the following: (a) The patient is stable on corticosteroids OR (b) Contraindication to corticosteroids
- Documentation the patient’s disease has relapsed or is refractory to standard of care therapy (i.e., corticosteroid treatment with or without immunosuppressive therapy)
Reauthorization criteria
- Documented diagnosis of eosinophilic granulomatosis with polyangiitis
- Patient age ≥ 18 years
- Prescribed by or in consultation with an allergist, immunologist, pulmonologist, or rheumatologist
- Documentation the patient has experienced a therapeutic response as defined by at least one (1) of the following: (a) A reduction in the frequency and/or severity of relapses OR (b) A reduction or discontinuation of doses of corticosteroids OR (c) Disease remission
Approval duration
initial 6 months; reauth 12 months