Subject: Specialty Quantity Limit Fasenra 2468-H P2024a
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional quantity may be provided up to the exception limit with prior authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
Exception
Limit*
|
FDA-recommended dosing
|
|
Fasenra (benralizumab) 10 mg/0.5 mL single-dose prefilled syringe
|
1 syringe per 56 days
|
3 syringes
per 84 days
|
Asthma
Adults and adolescent patients 12 years
of age and older
30 mg every 4 weeks for the first 3
doses, followed by 30 mg every 8 weeks
Pediatric patients 6 to 11 years of age
• < 35 kg: 10 mg every 4 weeks for the
first 3 doses, followed by 10 mg every
8 weeks
• ≥ 35 kg: 30 mg every 4 weeks for the
first 3 doses, followed by 30 mg every
8 weeks
Eosinophilic granulomatosis with
polyangiitis (EGPA)
30 mg every 4 weeks
|
*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
- Fasenra [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; September 2024.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
November 04, 2024
