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New Prior Authorization Criteria for Benralizumab for Texas Medicaid November 1, 2018

Last updated on 9/21/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after November 1, 2018, prior authorization criteria for benralizumab (procedure code C9466) will change for Texas Medicaid.

Prior authorization for benralizumab will be considered for clients who are 12 and older with severe asthma with an eosinophilic phenotype (as defined by the National Heart, Lung, and Blood Institute’s Guidelines for the Diagnosis and Management of Asthma).

Note: Providers may refer to the current Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, subsection 35.7, “Prior Authorization Criteria for Asthma – Moderate to Severe (Omalizumab) and Severe (Mepolizumab and Reslizumab),” for documentation requirements when submitting an initial prior authorization request for benralizumab.

Treatment of benralizumab may not be used concurrently with omalizumab or any other interleukin-5 antagonist.

Providers may not bill for an office visit if the only reason for the visit is a benralizumab injection.

Additional Documentation Requirements for Benralizumab

The following additional documentation for treatment with benralizumab must also be submitted with the initial prior authorization request:

  • Documented diagnosis of severe eosinophilic asthma
  • Blood eosinophil count greater than or equal to 150 cells/microliter before the initiation of therapy, in the absence of other potential causes of eosinophilia including hypereosinophilic syndromes, neoplastic disease, and known or suspected parasitic infection

Note: 1microliter (ul) is equal to 1 cubic millimeter (mm3)

  • Prior authorization for an initial request for benralizumab will be considered when the client meets the criteria for benralizumab, and has had an inadequate response after being compliant with 6 months of omalizumab treatment. Failure to respond to omalizumab must be documented in a letter, signed and dated by the prescribing provider, and submitted with the prior authorization request.

Note: Exceptions may be considered for clients who meet the requirements for treatment with benralizumab but who do not meet the criteria for omalizumab. Supporting documentation (IgE level falls outside of required range and/or negative skin test/RAST to a perennial aeroallergen) must be submitted along with the other required documentation for treatment with benralizumab.

Requirements for Continuation of Therapy

For continuation of therapy with benralizumab after 6 continuous months, the requesting provider must submit documentation of the client’s compliance and satisfactory clinical response to benralizumab.

Note: Providers may refer to the current Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, subsection 35.8, “Requirements for Continuation of Therapy,” for documentation requirements when submitting additional prior authorization requests for benralizumab.

For more information, call the TMHP Contact Center at 800-925-9126.