Tezspire (tezepelumab-ekko) for severe asthma
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Covers prior authorization criteria, dosing limits, documentation and billing codes for tezepelumab (Tezspire) use 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.
Medical Necessity Criteria for Tezspire (tezepelumab-ekko)
Initial authorization 97 severe asthma (6 months)
Authorization of 6 months may be granted when ALL of the following are met:
ANY of the following
- Two or more asthma exacerbations requiring oral or injectable corticosteroid treatment
- One or more asthma exacerbation resulting in hospitalization or emergency medical care visit
- Poor symptom control (frequent symptoms or reliever use, activity limited by asthma, night waking due to asthma)
ALL of the following
- Medium-to-high dose inhaled corticosteroid
- Additional controller (e.g., long-acting beta2-agonist, long-acting muscarinic antagonist, leukotriene modifier, or sustained-release theophylline)
Continuation authorization 97 severe asthma (12 months)
Authorization of 12 months may be granted when ALL of the following are met:
ANY of the following
- A reduction in the frequency and/or severity of symptoms and exacerbations
- A reduction in the daily maintenance oral corticosteroid dose
Not medically necessary
Tezspire is considered not medically necessary when the criteria above are not met:
ANY of the following
- Member does not meet the age requirement (under 12 years)
- Member does not have documentation of uncontrolled asthma as defined
- Member has not failed/been intolerant to medium-to-high dose inhaled corticosteroid plus an additional controller at maximally tolerated doses
- Member is using Tezspire concomitantly with another biologic indicated for asthma
Billing Codes for Tezspire
Dosing and quantity limits for billing
Approvals may be subject to dosing limits in accordance with FDA labeling, compendia, or evidence-based practice guidelines; quantity limits apply (210 mg per dose, 1 vial/syringe/pen per 28 days; FDA‑recommended dosing 210 mg every 4 weeks).
Authorization, Documentation, and Prescriber Requirements
Prior authorization required
Prior authorization is required; submit chart notes, medical records, or claims history documenting prior medications tried (drug, dose, frequency, duration) for initial requests, and documentation of improved asthma control for continuation requests.
Required documentation for initial and continuation requests
Initial requests: chart notes, medical record documentation, or claims history supporting previous medications tried including drug, dose, frequency, and duration. Continuation requests: chart notes or medical record documentation supporting improvement in asthma control.
Prescriber specialty requirement
Must be prescribed by or in consultation with an Allergist/Immunologist or Pulmonologist.
Denial if criteria unmet
Requests will be considered not medically necessary (denied) if the coverage criteria are not met, including age under 12 years, lack of documentation of uncontrolled asthma, failure to trial medium‑to‑high dose inhaled corticosteroid plus an additional controller at maximally tolerated doses, or concomitant use of another biologic indicated for asthma.
Clinical Context and Scope
Tezspire (tezepelumab-ekko) is an FDA-approved biologic indicated as an add-on maintenance treatment for adult and pediatric patients aged 12 years and older with severe asthma. Per the FDA-approved labeling and this policy, Tezspire is intended for maintenance therapy and is not indicated for relief of acute bronchospasm or status asthmaticus.
This policy covers prior authorization criteria, dosing limits, required documentation, prescriber specialty requirements, and applicable billing codes for Tezspire when used as add-on maintenance therapy for members aged 12 years and older with severe asthma. Initial authorizations may be granted for 6 months when all clinical criteria are met, and continuation authorizations may be granted for up to 12 months when improvement in asthma control is documented. Approvals are subject to dosing limits consistent with FDA labeling and quantity limits of one 210 mg vial/syringe/pen per 28 days. Prior authorization requires submission of chart notes or claims history documenting prior controller therapy and, for continuation requests, documentation of improved asthma control. Tezspire must be prescribed by or in consultation with an Allergist/Immunologist or Pulmonologist and must not be used concomitantly with other biologics indicated for asthma.
Defined Terms
Policy Information & Metrics
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