CommercialPrior AuthHigh impact
Reslizumab (Cinqair) (CPB 0907, reviewed 2026-08-10)
Aetna·Allergy & Immunology, Pulmonology·Medical Policy
Effective date
Aug 10, 2026
We identified it
Aug 15, 2026
Summary
Aetna updated its reslizumab (Cinqair) coverage policy for severe asthma treatment, effective immediately. The policy requires precertification for all commercial plans, restricts prescribing to allergists/immunologists or pulmonologists, and mandates specific clinical criteria including baseline eosinophil counts ≥400 cells/mcL or oral corticosteroid dependence, plus documented uncontrolled asthma despite high-dose ICS and additional controller therapy. Billing teams must implement prior authorization workflows and ensure claims include appropriate documentation before submission.
Action Required
IMMEDIATELY: (1) Billing team must establish prior authorization process for reslizumab (J2786) requiring precertification before claims submission by calling (866) 752-7021 or faxing (888) 267-3277. (2) Update billing software to flag J2786 claims and prevent processing without documented precertification approval. (3) Create clinical criteria checklist for prior auth requests: patient age ≥18, baseline eosinophil count ≥400 cells/mcL OR oral corticosteroid dependence, documented uncontrolled asthma in past 12 months (≥2 exacerbations requiring corticosteroids, OR 1+ hospitalization/ED visit, OR poor symptom control), and current high-dose ICS + additional controller at optimized doses. (4) Providers must document prescriber specialty (allergist/immunologist or pulmonologist) on all orders. (5) Update encounter templates to require Statement of Medical Necessity (SMN) completion for specialty pharmacy precertification per Utilization Management Policy on Site of Care for Specialty Drug Infusions. (6) Configure system to deny claims for J2786 billed in combination with J2182, J2356, or J2357 (other biologic asthma drugs). (7) For continuation therapy (renewals), require documentation of clinical improvement (reduced exacerbation frequency/severity or reduced/discontinued oral corticosteroid dose). Failure to obtain precertification will result in claim denials.