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    Fasenra™

    Drug - Fasenra™ (benralizumab) [AstraZeneca Pharmaceuticals LP.]

    July 2018

    Therapeutic area - Asthma

    Initial approval criteria

    • Patient must be 12 years of age or older AND
    • Has a diagnosis of  severe eosinophilic asthma with a documented blood eosinophiol count of either:
      • ≥150 cells/microliter at baseline or ≥ 300 cells/microliter in the past 12 months as documented in chart notes and
    • Patient’s symptoms are not well controlled despite a 3 month adherent trial of high-dose inhaled corticosteroids in combination with a long-acting bronchodilator or leukotriene modifier AND 
    • Patient has had 2 or more exacerbations requiring treatment with systemic corticosteroids in the past 12 months AND
    • Fasenra must be used as an add-on to BOTH high-dose inhaled corticosteroids AND an additional controller medication (e.g., long-acting beta-agonist, etc.) AND
    • Patient must not have concurrent use of Xolair, Nucala or Cinqair AND
    • At time of request, provide baseline FEV1 and frequency of asthma exacerbation per month
    • Initial approval will be for 6 months in duration

    Renewal approval criteria

    • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following:
      • Parasitic (helminth) infection
      • Herpes zoster infection
    • Treatment has resulted in clinical improvement as documented by at least ONE of the following:
      • Decreased frequency of exacerbations (defined as improvement of asthma as demonstrated by decreased use of oral/systemic corticosteroids and/or less frequent hospitalizations and/or reduced frequency of ER visits)
      • Improvement in lung function, measured in FEV1
    • Renewal approval will be for 12 months in duration

    Quantity Limits

    • Five injections (30mg/mL prefilled syringe) for the first 6 months
    • Six injections (30mg/mL prefilled syringe) for subsequent 12 months

    Billing of Fasenra

    Fasenra is not covered through the MHCP fee-for-service pharmacy benefit and must be submitted as a medical claim. Fasenra should be administered by a healthcare professional in a healthcare setting. In line with clinical practice, monitoring of patients after administration of biologic agents is recommended by the manufacturer.

    Questions?

    MHCP Provider Call Center 651-431-2700 or 800-366-5411

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