Tezspire (tezepelumab-ekko) for severe asthma — prior authorization and medical necessity criteria
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Covers prior authorization, documentation, and medical necessity criteria for Tezspire as add-on maintenance therapy in patients aged 12 years and older with severe asthma for Wellmark Blue Cross and Blue Shield members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Tezspire (tezepelumab-ekko)
Initial Therapy
Authorization of 6 months may be granted for treatment of severe asthma when ALL of the following are met:
Initial Therapy - prior biologic
Authorization of 6 months may be granted for members 12 years of age or older who have previously received a biologic drug indicated for asthma.
Continuation Therapy
Authorization of 12 months may be granted for continuation when ALL of the following are met:
Tezspire (tezepelumab-ekko) is approved as an add‑on maintenance treatment for patients aged 12 years and older with severe asthma. It has a specific limitation of use: Tezspire is not indicated for relief of acute bronchospasm or for treatment of status asthmaticus.
Tezspire is considered not medically necessary for members who do not meet the coverage criteria described for continuation or initiation of therapy. Authorization for continuation (up to 12 months) requires documentation that asthma control has improved on Tezspire (for example, reduced symptom/exacerbation frequency or reduced daily maintenance oral corticosteroid dose) and that the member will continue background maintenance asthma treatments and will not use Tezspire concomitantly with other biologics indicated for asthma.
Procedures, Dosing, and Quantity Limits
Prior Authorization, Documentation, and Provider Requirements
Prior Authorization Required
Prior authorization is required for Tezspire (tezepelumab-ekko). Initial authorizations may be granted for 6 months in specified situations; continuation authorizations may be granted for 6 or 12 months per criteria below.
Required Documentation
Initial requests must include chart notes, medical record documentation, or claims history documenting prior medications tried (drug name, dose, frequency, and duration). Continuation requests must include chart notes or medical record documentation supporting improvement in asthma control.
Required Prior Controller Therapy
Member must have inadequate asthma control despite treatment with both of the following at maximally tolerated doses: high‑dose inhaled corticosteroid AND an additional controller (e.g., long‑acting beta‑agonist, long‑acting muscarinic antagonist, leukotriene modifier, or sustained‑release theophylline). Member must continue maintenance asthma treatments in combination with Tezspire and must not use Tezspire concomitantly with other biologics indicated for asthma.
Denial Risk for Unmet Criteria
Tezspire will be considered not medically necessary and the request may be denied if the member does not meet the clinical criteria for initial or continuation therapy (age requirement, documented exacerbations or poor symptom control, prior biologic history where applicable, required prior controller therapy, and required documentation).
- Denial risk applies when documentation of prior medications, dosing/duration, or evidence of inadequate control/improvement on therapy is missing or incomplete.
- Denial risk applies if member is using another biologic for asthma concomitantly.
Background on Tezspire
Tezspire (tezepelumab-ekko) is indicated as an add‑on maintenance treatment for severe asthma in patients aged 12 years and older. Use is intended to be part of ongoing asthma management in combination with maintenance therapies and not for immediate relief of bronchospasm or acute asthma emergencies.
Limitations of Use and Definitions
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