CommercialPrior AuthMedium impact
Reslizumab (Cinqair®)
BCBS Tennessee·TN · Allergy & Immunology, Pulmonology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee is implementing a new coverage policy for Reslizumab (Cinqair®) for severe eosinophilic asthma in adults 18+. The policy establishes prior authorization requirements, clinical criteria (eosinophil count ≥400 cells/mcL or systemic corticosteroid dependence plus uncontrolled asthma), prescriber specialty restrictions (allergist/immunologist or pulmonologist only), and a dosing limit of 3mg/kg IV every 4 weeks. Initial authorizations are granted for 6 months, with continuation authorizations for 12 months if asthma control improves.
Action Required
Before December 1, 2026: (1) Billing team must update prior authorization workflow in billing system to require prior auth for Cinqair (HCPCS J2786) for all asthma claims. (2) Create prior authorization checklist requiring: baseline blood eosinophil count ≥400 cells/mcL OR systemic corticosteroid dependence, evidence of uncontrolled asthma within past 12 months (≥2 exacerbations requiring oral/injectable corticosteroids, OR ≥1 hospitalization/ED visit, OR poor symptom control), and documentation of high-dose ICS + additional controller at optimized doses. (3) Providers must add prescriber specialty validation to encounter forms—only allergist/immunologist or pulmonologist orders allowed; route denials if prescribed by other specialists. (4) Billing staff must enforce quantity limit of 3mg/kg every 4 weeks in billing system to prevent claim denials. (5) For continuation of therapy after initial 6-month period, require documentation of improved asthma control (reduced symptom/exacerbation frequency, reduced/discontinued oral corticosteroid dose). Failure to obtain prior authorization or meet clinical criteria will result in claim denials. Update clinical staff and prior auth team on new requirements.