CurrentBlue Cross Blue Shield - IowaPolicy 05.04.59

Tezspire (tezepelumab-ekko) for severe asthma — prior authorization and medical necessity criteria

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.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyTezspire (tezepelumab-ekko) for severe asthma — prior authorization and medical necessity criteria

Policy CodePolicy 05.04.59

Change TypeAdministrative (no material clinical changes)

Effective DateAug 18, 2025

Next Review Date

Key ActionObtain prior authorization with documentation of prior controller therapy, exacerbation history, and required medical records for initial or continuation approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=12minimum age eligible for coverage

210 mg q4wFDA-recommended dosing

1 per 28dquantity limits

6 moinitial auth (prior biologic)

12 mocontinuation auth (improved)

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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 authorization (6 months): Member is 12 years of age or older AND two or more asthma exacerbations requiring oral or injectable corticosteroid treatment AND member has uncontrolled asthma as demonstrated by at least one of: (a) one or more exacerbation resulting in hospitalization or emergency medical care visit OR (b) poor symptom control (frequent symptoms or reliever use, activity limited by asthma, night waking due to asthma) AND member has inadequate asthma control despite current treatment with BOTH: (i) high‑dose inhaled corticosteroid AND (ii) additional controller (long‑acting beta‑agonist, long‑acting muscarinic antagonist, leukotriene modifier, or sustained‑release theophylline) at maximally tolerated doses AND member will continue maintenance asthma treatments (e.g., inhaled corticosteroid and additional controller) in combination with Tezspire AND member will not use Tezspire concomitantly with other biologics indicated for asthma (e.g., Cinqair, Dupixent, Fasenra, Nucala, Xolair)

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.

Initial authorization (prior biologic): Member is 12 years of age or older AND member previously received a biologic indicated for asthma (e.g., Fasenra, Nucala, Tezspire, Xolair, Cinqair)

Continuation Therapy

Authorization of 12 months may be granted for continuation when ALL of the following are met:

Continuation authorization (12 months): Member is 12 years of age or older AND asthma control has improved on Tezspire as demonstrated by at least one of: (a) reduction in the frequency and/or severity of symptoms and exacerbations OR (b) reduction in the daily maintenance oral corticosteroid dose AND member will continue maintenance asthma treatments (e.g., inhaled corticosteroid and additional controller) in combination with Tezspire AND member will not use Tezspire concomitantly with other biologics indicated for asthma (e.g., Cinqair, Dupixent, Fasenra, Nucala, Xolair)

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

Procedures and billing codesHCPCS

J3590	unclassified biologics
C9399	unclassified drugs or biologics
J2356	Injection, tezepelumab-ekko, 1mg

Dosing interval

FDA-recommended dose210 mg every 4 weeks

Presentation210 mg / 1.91 mL single-dose glass vial, pre-filled syringe, or pre-filled pen

Quantity limit1 vial/syringe/pen per 28 days

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

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.

Quantity limit: 210 mg every 4 weeks (vial, pre-filled syringe, or pre-filled pen) — 1 unit per 28 days.
Billing/Codes: J3590; C9399; J2356.

Documentation Required

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.

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

Limitations of Use

Limitations of use (primary)Not for relief of acute bronchospasm or status asthmaticus

Indication contextAdd-on maintenance treatment for severe asthma in patients aged 12 years and older

Implication for acute careShould not be used for emergency treatment of asthma exacerbations