Does J2786 require prior authorization?

Yes, J2786 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J2786?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J2786`, Injection, reslizumab, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Initial PA requires chart notes showing pre-treatment eosinophil count or systemic corticosteroid dependence and documentation of prior medications tried (drug, dose, frequency, duration); continuation PA requires chart notes showing improvement in asthma control.
For continuation requests, provide chart notes showing improvement in asthma control.
Prescriber must be an allergist/immunologist or pulmonologist (or in consultation with one).
Documentation of positive clinical response as demonstrated by at least one of the following: o Reduction in the frequency of exacerbations o Decreased utilization of rescue medications o Increase in percent predicted FEV1 from pretreatment baseline o Reduction in severity or frequency of asthma-related symptoms

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Add-on maintenance therapy for adults (≥18) with severe asthma and eosinophilic phenotype.
Nucala for provider administration is proven for add-on therapy for patients who meet both of the following criteria: o Has an eosinophilic phenotype; and o Will be used as add-on maintenance therapy in the treatment of severe asthma
Medically necessary for Fasenra (benralizumab) for provider administration in EGPA when there is a diagnosis of EGPA with relapsing or refractory disease, defined by a history of EGPA and asthma plus at least two EGPA-typical features (histopathologic eosinophilic vasculitis, perivascular eosinophilic infiltration, eosinophil-rich granulomatous inflammation).
Initial prior authorization validity is 12 months (365 days).

20 Active Policies

ARKBLUE-RESLIZUMAB-E-G-CINQAIR-8EECCCBFBF, Reslizumab (e.g., Cinqair)

FLORIDA_BLUE-FLBLUE-CINQAIR-RESLIZUMAB-1990825C4B, Cinqair (Reslizumab)

BCBSLA-00511-D7F008A1AF, 00511 reslizumab (Cinqair)

BCBSM-2071693-BC3250EF70, CINQAIR (RESLIZUMAB)

BCBSNJ-DRUGS-133-2ADC519856, Monoclonal Interleukin-5 Antagonists [mepolizumab (Nucala), reslizumab (Cinqair), and benralizumab (Fasenra)]

MODA-CINQAIR-84B315F3D9, Cinqair (reslizumab)

HEALTHNET_OR-HNOR-RESLIZUMAB-CINQAIR-CP-PHAR-223-7F512F65FB, Reslizumab (Cinqair); CP.PHAR.223

IBX-MEDICARE-ADVANTAGE-MA08-024O-D2920CA97B, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair, Exdensur, Nucala) and IL-5 Receptor Antagonist (e.g., Fasenra)

IBX-COMMERCIAL-08-01-23K-B6E824CB59, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair, Exdensur)

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-respiratory-interleukins, Respiratory Interleukins (Cinqair, Fasenra, & Nucala)

SUREST-POL-SUREST-respiratory-interleukins, Respiratory Interleukins (Cinqair, Fasenra, & Nucala)

AMERIHEALTH-COMMERCIAL-08-01-23K-F0DFBBFF21, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair, Exdensur)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-024O-19BF620A89, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair, Exdensur, Nucala) and IL-5 Receptor Antagonist (e.g., Fasenra)

BCBSTN-008271868c, Reslizumab (Cinqair)

EVICORE-MEDICAL_DRUG-70CCE2097828, Cinqair (reslizumab)

UHC-COMM-MD-RESPIRATORY-INTERLEUKINS-CINQAIR-FASENRA-3476B9F5B6, Respiratory Interleukins (Cinqair, Fasenra, & Nucala) – Community Plan Medical Benefit Drug Policy

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UHC-EXCH-MD-RESPIRATORY-INTERLEUKINS-CINQAIR-FASENRA-0A5E0CE7F5, Respiratory Interleukins (Cinqair, Fasenra, & Nucala) – Individual Exchange Medical Benefit Drug Policy

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J2786, Injection, reslizumab, 1 mg