Benralizumab (Fasenra) — CPB 0925 | AETNA Coverage Update

Aetna modified CPB 0925 for benralizumab (Fasenra), effective January 5, 2026. Here's what billing teams need to know before submitting claims under this updated coverage policy.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0925 Aetna system to revise medical necessity criteria for benralizumab (Fasenra) — the anti-IL-5 receptor alpha biologic billed under HCPCS J0517. The changes affect initial approval criteria for asthma and eosinophilic granulomatosis with polyangiitis (EGPA), with new step-therapy language that will directly drive claim denial rates if your documentation doesn't match. If your practice treats severe asthma or EGPA and bills J0517 to Aetna commercial plans, this policy affects your reimbursement workflow starting now.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Benralizumab (Fasenra) — CPB 0925
Policy Code	CPB 0925
Change Type	Modified
Effective Date	January 5, 2026
Impact Level	High
Specialties Affected	Allergist/Immunologist, Pulmonologist
Key Action	Audit prior authorization documentation for J0517 against new step-therapy and eosinophil count criteria before submitting claims

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Aetna Benralizumab Coverage Criteria and Medical Necessity Requirements 2026

The Aetna benralizumab coverage policy under CPB 0925 requires precertification for all participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to initiate prior authorization. Statement of Medical Necessity forms are available through Aetna's Specialty Pharmacy Precertification portal.

Aetna also applies a Site of Care Utilization Management policy to benralizumab. That means where you administer this drug matters for reimbursement. Review Aetna's drug infusion site-of-care policy before scheduling administration.

Prescribing Specialty Requirement

Benralizumab must be prescribed by — or in documented consultation with — an allergist/immunologist or pulmonologist for the asthma indication. This is a hard requirement. A prescription from a primary care provider without a specialist consultation on record is a clean path to denial.

Asthma: Initial Approval Criteria

This is where the updated coverage policy adds the most complexity. Aetna considers benralizumab medically necessary for asthma under two separate tracks.

Track 1 — Prior Biologic Use:
Members age six or older who received a biologic indicated for asthma (such as Dupixent or Nucala, billed under J2182 for mepolizumab or J2357 for omalizumab) within the past year qualify under this track. This is Aetna's step-therapy shortcut. If your patient already failed or is currently on another asthma biologic, document that clearly in your prior authorization request.

Track 2 — Severe Asthma, No Prior Biologic:
All five of the following must be met:

The real issue here is the eosinophil count threshold. Make sure blood count labs — billed under CPT 85004 (automated differential WBC) or CPT 85048 (automated leukocyte count) — are documented in the record and reflected in the prior auth submission. Missing lab data is one of the top drivers of prior authorization denials for biologics.

EGPA: Initial Approval Criteria

For eosinophilic granulomatosis with polyangiitis, Aetna again uses a two-track approach.

Track 1 — Prior Biologic Use:
Members age 18 or older who received a biologic indicated for EGPA (such as Nucala/mepolizumab, J2182) in the past year.

Track 2 — De Novo EGPA Treatment:
All four of these must be met:

The eosinophil threshold for EGPA (greater than 1,000 cells/µL) is notably higher than for asthma (at least 150 cells/µL). Don't mix these up in your documentation. A prior auth submission with the wrong eosinophil threshold cited for the wrong indication will come back denied.

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Aetna Benralizumab Exclusions and Non-Covered Indications

The policy data does not enumerate a separate exclusions list, but the structure of CPB 0925 makes the exclusions clear by implication. Benralizumab is not covered for:

If your patient doesn't clearly fit one of the two tracks for each indication, assume the claim will be denied on medical necessity grounds.

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Coverage Indications at a Glance

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Aetna Benralizumab Billing Guidelines and Action Items 2026

These are specific steps for billing teams and revenue cycle staff handling J0517 claims on Aetna commercial plans after January 5, 2026.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Benralizumab Under CPB 0925

Primary Covered HCPCS Code

Code	Type	Description Copy
J0517	HCPCS	Injection, benralizumab, 1 mg

Supporting CPT Codes (Related to Criteria and Administration)

Corticosteroid and Comparator Biologic HCPCS Codes Referenced in CPB 0925

These codes appear in the policy as comparator or concomitant medications. They're relevant for documenting prior biologic use and corticosteroid dependence in your prior authorization submissions.

Key ICD-10-CM Diagnosis Codes

For asthma claims, J45.50–J45.52 are your primary diagnosis codes. For EGPA, M30.1 (Churg-Strauss) is the correct ICD-10 code. The J44.x COPD codes appear in the policy reference data but benralizumab is not approved for COPD under this bulletin — don't use them as the primary diagnosis for a Fasenra claim.

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