CurrentAvMedPolicy N/A

Tezspire (tezepelumab) prior authorization / step-edit

Requirements and clinical criteria for pharmacy prior authorization and step-edit approval of Tezspire (tezepelumab) for members of the Health Plan; applies to prescribers requesting coverage via specialty pharmacy.

Policy Summary

PayerAvMed

PolicyTezspire (tezepelumab) prior authorization / step-edit

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must sign and print their name on the prior authorization request form and fax the completed form to the specified number.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsApproval duration

≥12 yrsMin age

210 mg q4wDose

Specialty PharmacyDispensed by

Coverage Criteria for Tezspire (tezepelumab)

Initial Therapy — Severe Asthma

Covered when ALL of the following are met:

Severe Asthma initial: Member has a confirmed diagnosis of severe asthma

Severe Asthma initial: Prescribed by or in consultation with an allergist, immunologist, or pulmonologist

Severe Asthma initial: Member is 12 years of age or older

Severe Asthma initial: Member has been compliant with required controller therapy for at least 90 consecutive days within a year prior to request (verified by pharmacy paid claims); therapy must be ONE of: high‑dose inhaled corticosteroid (e.g., >500 mcg fluticasone propionate equivalent/day) plus an additional controller OR one maximally dosed combination ICS/LABA product

Policy Summary

PayerAvMed

PolicyTezspire (tezepelumab) prior authorization / step-edit

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must sign and print their name on the prior authorization request form and fax the completed form to the specified number.

SourceLink

On This Page

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Reauthorization — Severe Asthma

Covered when ALL of the following are met:

Severe Asthma reauth: Member has experienced a sustained positive clinical response to Tezspire as demonstrated by at least ONE of: increase in percent predicted FEV1 from baseline; reduction in inhaled corticosteroid dose; reduction in oral corticosteroid use; reduction in asthma symptoms (e.g., chest tightness, coughing, shortness of breath, nocturnal awakenings)clinical response

Severe Asthma reauth: Member is currently being treated with ONE of the required controller regimens (verified by pharmacy paid claims): high‑dose ICS plus an additional controller OR one maximally dosed combination ICS/LABA product

Therapy compliance verified by pharmacy paid claims

Severe Asthma reauth: All documentation supporting each checked criterion (lab results, diagnostics, and chart notes) must be provided or request may be denied

Initial Therapy — CRSwNP

Covered when ALL of the following are met:

CRSwNP initial: Prescribed by or in consultation with an allergist, immunologist, or otolaryngologist

CRSwNP initial: Member is 12 years of age or older

CRSwNP initial: Diagnosis of CRSwNP confirmed per AAO‑HNSF/AAAAI guideline with ONE of the following objective procedures: anterior rhinoscopy, nasal endoscopy, or computed tomography (CT)

CRSwNP initial: Chronic rhinosinusitis documented as at least 12 weeks of mucosal inflammation plus at least TWO of: decreased sense of smell; facial pressure/pain/fullness; mucopurulent drainage; nasal obstruction

CRSwNP initial: Member has tried and failed intranasal corticosteroids for at least 30 consecutive days within a year prior to request (verified by pharmacy paid claims)30 days intranasal corticosteroids

Verified by pharmacy paid claims

CRSwNP initial: Tezspire is requested as add‑on to maintenance intranasal corticosteroids

CRSwNP initial: All required documentation (e.g., anterior rhinoscopy/nasal endoscopy/CT reports, chart notes, pharmacy paid claims) must be provided

Reauthorization — CRSwNP

Covered when ALL of the following are met:

CRSwNP reauth: Member has experienced a positive clinical response to Tezspire (examples: reduced nasal polyp size, improved nasal congestion, reduced sinus opacification, decreased sino‑nasal symptoms, improved sense of smell, reduced use of oral corticosteroids)

CRSwNP reauth: Member has been compliant with Tezspire therapy and continues to receive maintenance intranasal corticosteroid therapy (verified by pharmacy paid claims)

Compliance verified by pharmacy paid claims

CRSwNP reauth: All documentation supporting clinical response and continued background therapy must be provided (e.g., diagnostic reports, chart notes, pharmacy paid claims) or request may be denied

Step Therapy Requirements

Required prior controller therapy	Compliance requirement	Notes
High‑dose inhaled corticosteroid (ICS) (e.g., >500 mcg fluticasone propionate equivalent/day) PLUS an additional asthma controller (e.g., leukotriene receptor antagonist, LABA, theophylline)	>= 90 consecutive days within a year (verified by pharmacy paid claims)	Member must be compliant on therapy unless contraindicated or intolerant
One maximally dosed combination ICS/LABA product (e.g., Advair, Dulera, Symbicort)	>= 90 consecutive days within a year (verified by pharmacy paid claims)	Examples listed in form; compliance verification via pharmacy paid claims

Required prior therapy	Duration	Verification / Notes
Intranasal corticosteroids (maintenance)	>= 30 consecutive days within a year	Failure of intranasal corticosteroids must be documented; verified by pharmacy paid claims

Provider Actions and Documentation Requirements

Prior Authorization

Submission and signature requirement

The prescribing physician must sign and clearly print their name (preprinted stamps not valid) on the prior authorization request form. All other information may be filled in by office staff. Fax the completed form to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing phone/fax numbers) may delay processing or result in denial.

Prescriber signature and printed name required on PA form (stamps not valid)
Fax completed form to 1-305-671-0200
Ensure phone and fax numbers are included and legible

Denial Risk

Prohibited concomitant biologic therapy

The Health Plan considers concomitant use of Tezspire (tezepelumab) with Cinqair, Dupixent, Fasenra, Nucala, or Xolair to be experimental and investigational. Safety and efficacy of these combinations have not been established and concomitant therapy will not be permitted. If a member has an active authorization for Cinqair, Dupixent, Fasenra, Nucala, or Xolair on file, subsequent requests for Tezspire will not be approved.

Prohibited concomitant biologics: Cinqair®, Dupixent®, Fasenra®, Nucala®, Xolair®
Active authorizations for the listed biologics will preclude approval of Tezspire

Documentation Required

Required supporting documentation

All required supporting documentation must be submitted to support clinical criteria. This includes, but is not limited to, chart notes, laboratory results, diagnostic reports (e.g., spirometry, CT, nasal endoscopy), and pharmacy paid-claim history verifying prior controller therapy. Failure to provide requested documentation or submitting incomplete/illegible records may result in delay or denial of the request.

Provide chart notes, lab results, and diagnostic reports to support each checked clinical criterion
Submit pharmacy paid-claim history to verify prior controller therapy and prior use of intranasal corticosteroids when applicable
Incomplete or missing documentation may cause denial

Documentation Required

Asthma-specific documentation

For asthma indications, include baseline FEV1 with the year the test was performed, documentation of prior controller therapy (verified by pharmacy paid claims) showing at least 90 consecutive days of compliance within the prior year unless contraindicated or intolerant, and records of exacerbations (e.g., courses of oral corticosteroids, ED/urgent care visits, hospitalizations, or prior intubation).

Baseline FEV1 (% predicted) with year (FEV1 < 80% predicted for adults; < 90% for ages 12–17)
Evidence of ≥90 days continuous use of required controller therapy within past year (pharmacy paid claims)
Documentation of exacerbations (oral steroids, ED/urgent care visits, hospitalizations) or any prior intubation

Note

Approval duration

Initial and reauthorization approvals are granted for 12 months when all clinical criteria and documentation requirements are met.

Approval duration: 12 months for initial and continuation authorizations

Step Therapy

Step-edit: required prior controller therapy

Member must be currently treated with one of the specified controller regimens unless there is a documented contraindication or intolerance. Acceptable regimens include high-dose inhaled corticosteroid (ICS) plus an additional controller medication (e.g., leukotriene receptor antagonist, LABA, theophylline) or a maximally dosed combination ICS/LABA product. Compliance on therapy for at least 90 consecutive days within the prior year is required and must be verified by pharmacy paid claims.

Required prior controller therapy: high-dose ICS + additional controller OR maximally dosed ICS/LABA
Document contraindication/intolerance if not meeting step-edit
Verify ≥90 days continuous therapy within past 12 months via pharmacy paid claims

Documentation Required

Form completeness and legibility

Ensure the PA form is complete and legible. Incomplete or illegible forms may delay the review process or lead to denial. Include contact information for the prescribing office to avoid unnecessary follow-up.

Incomplete/illegible forms can delay or cause denial
Include office contact name, phone, fax, and NPI

Definitions and Diagnostic Criteria

Chronic rhinosinusitis (CRSwNP) — definition

Duration criterionChronic rhinosinusitis defined as at least 12 weeks of mucosal inflammation

Symptom requirementAt least two of: decreased sense of smell; facial pressure/pain/fullness; mucopurulent drainage; nasal obstruction

Diagnostic confirmation examplesObjective procedure required: anterior rhinoscopy, nasal endoscopy, or CT

Severe asthma — criteria for initial therapy

Exacerbation historyOne or more exacerbations requiring additional medical treatment (e.g., oral corticosteroids, ED/UC visits, or hospitalizations within the past 12 months)

Prior intubationAny prior intubation for an asthma exacerbation

Prior controller failureMember must have been compliant on required controller therapy (see prior controller duration) prior to request

Prescriber requirementPrescribed by or in consultation with an allergist, immunologist, or pulmonologist

Initial Therapy Criteria by Indication

Initial therapy — indication-specific

Covered when ALL of the following indication‑specific criteria are met:

Initial: Severe Asthma: See 'Initial Therapy — Severe Asthma' criteria: confirmed severe asthma; age >= 12; specialist prescribing/consultation; required prior controller therapy compliant >=90 consecutive days; history of exacerbation, prior intubation, or FEV1 below threshold

All documentation required

Initial: CRSwNP: See 'Initial Therapy — CRSwNP' criteria: CRSwNP confirmed by guideline‑recommended objective procedure; chronicity and symptom criteria met; failed intranasal corticosteroids >=30 consecutive days; requested as add‑on to maintenance intranasal corticosteroids

All documentation required

Continuation / Reauthorization Criteria

Continuation therapy — Reauthorization requirements

Covered when ALL of the following are met:

Tezspire continuation: Member has demonstrated clinical benefit from Tezspire as specified for the treated indication (see indication‑specific reauthorization criteria)

Tezspire continuation: Member remains compliant with Tezspire therapy and continues required background therapy for the indication (e.g., intranasal corticosteroids for CRSwNP)

Verified by chart notes and pharmacy paid claims

Tezspire continuation: Supporting documentation (lab results, diagnostics, chart notes, pharmacy paid claims) demonstrating response and ongoing compliance must be provided or request may be denied

OpenPayer

Tezspire (tezepelumab) prior authorization / step-edit

Coverage Criteria for Tezspire (tezepelumab)

Step Therapy Requirements

Coding and Objective Measures

Provider Actions and Documentation Requirements

Definitions and Diagnostic Criteria

Initial Therapy Criteria by Indication

Continuation / Reauthorization Criteria

Quantity Limits and Dosing

Site of Care / Benefit Assignment

Background