Fasenra® (benralizumab)

Coverage is provided in the following conditions:

Universal Criteria

 Must not be used in combination with another anti-IgE, anti-IL4, or anti-IL5 monoclonal antibody (e.g., omalizumab, mepolizumab, reslizumab, dupilumab, etc.); AND

 Must NOT be used for either of the following:

o Treatment of other eosinophilic conditions (e.g., allergic bronchopulmonary aspergillosis/mycosis, Churg-Strauss syndrome, hypereosinophilic syndrome, etc.)

o Relief of acute bronchospasm or status asthmaticus; AND