Tezepelumab (Tezspire) — Coverage Criteria for Severe Asthma and CRSwNP
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Covers medical necessity, prior authorization, and coverage criteria for Tezepelumab (Tezspire) as add-on maintenance therapy in members aged 12 and older with severe asthma or chronic rhinosinusitis with nasal polyps (CRSwNP) for BlueCross BlueShield of Tennessee.
No material clinical or coverage changes in this revision.
Coverage Criteria for Tezepelumab (Tezspire)
Initial Therapy — Severe Asthma
Covered when ALL of the following are met:
Authorization of 6 months may be granted for members with prior biologic use in the past year.
Continuation Therapy — Severe Asthma
Covered when ALL of the following are met:
Authorization of 12 months may be granted.
Initial Therapy — CRSwNP
Covered when ALL of the following are met:
Authorization of 6 months may be granted for members with prior biologic use in the past year.
Continuation Therapy — CRSwNP
Covered when BOTH of the following are met:
Authorization of 12 months may be granted.
Use of Tezepelumab (Tezspire) for relief of acute bronchospasm or status asthmaticus is excluded from coverage.
Requests for Tezepelumab that would involve concomitant use with any other biologic drug or targeted synthetic drug for the same indication are not allowed and will not be covered.
Any use of Tezepelumab outside the FDA‑approved indications and the compendial uses described in this policy is considered experimental/investigational and not medically necessary, and therefore not covered.
Medication Dosing, Scoring, and Coding
| Tezspire (Tezepelumab) 210 mg | Route: Subcutaneous; dosing regimen listed as 210 mg every 4 weeks |
Prior Authorization and Documentation Requirements
Prior authorization required; duration limits
Prior authorization is required for Tezepelumab. Initial approvals may be granted for 6 months when the specified initial clinical criteria are met; continuation approvals may be granted for 12 months when continuation criteria are met and documentation supports ongoing benefit.
Required prior/concurrent therapies (asthma and CRSwNP)
For severe asthma, the member must have inadequate control despite optimized treatment with BOTH a high‑dose inhaled corticosteroid and an additional controller (LABA, LAMA, leukotriene modifier, or sustained‑release theophylline); authorization of 6 months may be granted for members with prior biologic use in the past year. For CRSwNP, member must have persistent bilateral polyposis despite intranasal corticosteroid for ≥4 weeks (unless contraindicated) and prior sino‑nasal surgery or ineffective systemic corticosteroid within last 2 years as described.
- Asthma: high‑dose inhaled corticosteroid plus an additional controller at optimized doses required.
- CRSwNP: intranasal corticosteroid ≥4 weeks (unless contraindicated) and prior surgery or prior systemic corticosteroid within 2 years (ineffective) required.
- Documentation of prior biologic use in the past year may affect authorization duration (possible 6‑month initial approval).
Documentation required for initial and continuation requests
Initial prior‑authorization requests must include chart notes, medical records, or claims history documenting prior medications tried (drug name, dose, frequency, and duration) and applicable objective assessments (e.g., nasal endoscopy/CT, Meltzer Clinical Score, or endoscopic NPS). Continuation requests must include chart notes or medical records documenting clinical improvement or a positive response to therapy.
- Initial asthma requests: chart notes/claims history showing previous medications tried with drug, dose, frequency, and duration.
- Initial CRSwNP requests: chart notes showing nasal endoscopy/CT details, Meltzer score or endoscopic NPS, and prior medication history; if therapy not advisable, document clinical reason.
- Continuation requests: chart notes documenting improvement in asthma control or positive clinical response for CRSwNP.
Non‑covered indications and prohibition on concomitant biologics
Tezepelumab is not covered for indications other than the FDA‑approved uses (severe asthma and CRSwNP) and requests where the medication would be used concomitantly with another biologic or targeted synthetic drug for the same indication are not allowed.
- All other indications are considered experimental/investigational and not medically necessary.
- Member cannot use Tezepelumab concomitantly with any other biologic drug or targeted synthetic drug for the same indication.
Background on Tezepelumab
Tezepelumab (Tezspire) is an add‑on maintenance biologic indicated for severe asthma and for inadequately controlled chronic rhinosinusitis with nasal polyps (CRSwNP) in patients aged 12 years and older. It is administered subcutaneously per the dosing regimen described in the policy and is not intended for relief of acute bronchospasm or status asthmaticus.
Key Definitions and Scoring
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