CommercialPrior AuthHigh impact
Benralizumab (Fasenra) (CPB 0925, reviewed 2025-12-23)
Aetna·Allergy & Immunology, Pulmonology, Rheumatology +1 more·Medical Policy
Effective date
Dec 23, 2025
We identified it
Aug 12, 2026
Summary
Aetna updated its Clinical Policy Bulletin (CPB 0925) for Benralizumab (Fasenra) effective December 23, 2025. This policy establishes coverage criteria for asthma and eosinophilic granulomatosis with polyangiitis (EGPA) with mandatory precertification requirements, specialty prescriber restrictions (allergist/immunologist or pulmonologist for asthma), and specific clinical thresholds including eosinophil counts and prior biologic drug history. Billing teams must implement prior authorization workflows immediately and ensure claims include required clinical documentation.
Action Required
IMMEDIATE (Effective December 23, 2025): Billing team must implement mandatory precertification requirement for all Benralizumab (Fasenra) claims billed under HCPCS code J0517. Update billing system to: (1) Flag all J0517 claims for prior authorization through Aetna at (866) 752-7021 or fax (888) 267-3277 before claim submission; (2) Require providers to submit Statement of Medical Necessity (SMN) precertification forms via Specialty Pharmacy Precertification; (3) Verify prescriber specialty (allergist/immunologist or pulmonologist for asthma indications only) before processing; (4) Document baseline eosinophil counts (≥150 cells/mcL for asthma OR >1000 cells/mcL or >10% for EGPA) in patient records; (5) Verify prior biologic therapy use within past 12 months if claiming first approval pathway. Update encounter forms and clinical documentation templates to capture required criteria. Ensure providers counsel current smokers/vapers on cessation. Claims submitted without precertification or incomplete clinical documentation will be denied. This policy applies only to Aetna commercial plans; refer Medicare beneficiaries to Medicare Part B Criteria.