CurrentCommunity-CarePolicy N/A

Tezspire (tezepelumab) Medical Benefit Medication Utilization Policy

Defines coverage, initial and continuation criteria, quantity limits, authorization periods, and applicable billing code for tezepelumab for severe asthma and chronic rhinosinusitis with nasal polyps for Community-Care members.

Policy Summary

PayerCommunity-Care

PolicyTezspire (tezepelumab) Medical Benefit Medication Utilization Policy

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateN/A

Next Review DateDecember 2025

Key ActionObtain prior authorization with documentation meeting initial approval criteria and confirm positive clinical response for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12minimum age for covered indications

≥2required asthma exacerbations (year)

1/28 daysquantity limit

6 moinitial auth (asthma)

J2356billing code

Coverage Criteria for Tezepelumab (Tezspire)

Initial Therapy - Severe asthma

Covered when ALL of the following are met:

Severe asthma initial approval criteria: (i) Age ≥ 12 years; (ii) Prescribed by, or in consultation with, an allergist, pulmonologist, or immunologist; (iii) Diagnosis of severe asthma; (iv) History of ≥2 asthma exacerbations requiring systemic corticosteroids or emergency department visit or hospitalization for asthma within the past year despite adherent use of either an inhaled corticosteroid plus one additional controller medication OR maximally tolerated ICS/LABA; (v) Prescriber attests that the patient is adherent to controller medications AND that tezepelumab will not be used in combination with another targeted immunomodulator product for asthma

Initial Therapy - Chronic rhinosinusitis with nasal polyps

Covered when ALL of the following are met:

CRSwNP initial approval criteria: (i) Age ≥ 12 years; (ii) Prescribed by, or in consultation with, an allergist, immunologist, or otolaryngologist; (iii) Diagnosis of chronic rhinosinusitis with nasal polyposis lasting ≥12 weeks; (iv) Bilateral nasal polyposis confirmed by nasal endoscopy or sinus CT; (v) Trial of a nasal corticosteroid spray was ineffective, contraindicated, or not tolerated; (vi) Moderate to severe symptoms of nasal congestion, blockage, or obstruction (eg, loss of smell, rhinorrhea, or facial pain)

Policy Summary

PayerCommunity-Care

PolicyTezspire (tezepelumab) Medical Benefit Medication Utilization Policy

Policy CodePolicy N/A

Change TypeMinor / No material change

Effective DateN/A

Next Review DateDecember 2025

Key ActionObtain prior authorization with documentation meeting initial approval criteria and confirm positive clinical response for continuation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required with documentation meeting the initial approval criteria for the applicable indication. Continuation of therapy also requires prior authorization with documentation of positive clinical response and confirmation that tezepelumab will not be used in combination with another targeted immunomodulator for asthma.

Applies to indications: severe asthma and chronic rhinosinusitis with nasal polyps
Initial authorization: must meet the Coverage Determination Criteria for Initial Approval (age ≥12, specialist prescriber or consultation, diagnostic and trial history as applicable)
Continuation authorization: must document positive clinical response and ongoing eligibility per continuation criteria
Quantity limits: 1 prefilled syringe or pen per 28 days if approved
Authorization periods: initial — severe asthma 6 months, chronic rhinosinusitis with nasal polyps 4 months; continuation — 1 year

Step Therapy

Step Therapy / Prerequisite Controller Therapy

For severe asthma, members must have a documented history of adherent use of an inhaled corticosteroid plus one additional controller medication, or maximally tolerated ICS/LABA combination, and have experienced ≥2 asthma exacerbations in the prior 12 months despite that controller therapy. Prescriber must be an allergist, pulmonologist, or immunologist, or there must be documentation of consultation. Prescriber must attest that tezepelumab will not be used concomitantly with another targeted immunomodulator for asthma.

Age requirement: ≥ 12 years
Exacerbation history: ≥ 2 exacerbations in past year requiring systemic corticosteroids, ED visit, or hospitalization despite controller adherence
Prescriber specialty: allergist, pulmonologist, or immunologist (or consult documented)
Attestation: adherence to controller meds and no concomitant targeted immunomodulator

Documentation Required

Required Documentation

Documentation submitted with the prior authorization request must include the diagnosis (severe asthma or chronic rhinosinusitis with nasal polyposis), patient age (≥12), prescriber specialty or evidence of specialist consultation, relevant diagnostic confirmation (e.g., bilateral nasal polyposis on endoscopy or CT for CRSwNP), prior medication trials and intolerance/contraindication notes, and records supporting exacerbation history or positive clinical response as applicable.

For CRSwNP: confirmation of bilateral nasal polyposis by nasal endoscopy or sinus CT and trial of nasal corticosteroid spray (ineffective, contraindicated, or not tolerated)
For severe asthma: documentation of ≥2 exacerbations in past year despite controller adherence
Evidence of positive clinical response for continuation requests
Medication history and prescriber attestation regarding concomitant biologic use

Denial Risk

Triggers for Denial

Requests may be denied if required documentation is missing or criteria are not met. Common triggers for denial include lack of documented exacerbation history despite controller adherence, absence of specialist prescriber or consultation, missing confirmation of bilateral nasal polyposis or failed/contraindicated nasal steroid trial for CRSwNP, or evidence of concurrent use with another targeted immunomodulator for asthma.

No documented ≥2 asthma exacerbations in past year despite adherent controller therapy
No specialist prescriber or documented consultation
For CRSwNP: no objective confirmation of bilateral nasal polyps or no trial of nasal corticosteroid documented
Request indicates concomitant use with another targeted immunomodulator for asthma

Background

Tezspire (tezepelumab) is a targeted immunomodulator indicated for treatment of severe asthma and for chronic rhinosinusitis with nasal polyps in patients ≥ 12 years of age. For severe asthma, coverage is targeted to patients with a diagnosis of severe asthma who have a history of ≥ 2 asthma exacerbations in the prior year requiring systemic corticosteroids, an emergency department visit, or hospitalization despite adherent use of either an inhaled corticosteroid plus one additional controller medication or a maximally tolerated ICS/LABA combination. For CRSwNP, the policy requires disease duration of at least 12 weeks, confirmation of bilateral nasal polyposis by nasal endoscopy or sinus CT, and a trial of a nasal corticosteroid spray that was ineffective, contraindicated, or not tolerated, with moderate to severe symptoms (for example loss of smell, rhinorrhea, or facial pain).

Definitions and Clinical Terms

Positive clinical response

DefinitionClinically meaningful improvement in disease control or symptoms as documented by the prescriber (required for continuation of therapy).

DocumentationPrescriber must attest to observed improvement in disease control or symptoms in medical record for continuation approvals.

Role in continuationRequired element for continuation of therapy for both severe asthma and CRSwNP per policy continuation criteria.

Severe asthma

DefinitionAsthma with ≥2 exacerbations in the past year requiring systemic corticosteroids, emergency department visit, or hospitalization despite adherent controller therapy.

Age requirementPatient must be ≥ 12 years of age for initial approval.

Controller adherenceExacerbations must have occurred despite adherent utilization of either an inhaled corticosteroid plus one additional controller medication or maximally tolerated ICS/LABA.

PrescriberMust be prescribed by, or in consultation with, an allergist, pulmonologist, or immunologist for initial approval.

Chronic rhinosinusitis with nasal polyposis (CRSwNP)

DefinitionChronic rhinosinusitis with bilateral nasal polyps lasting at least 12 weeks confirmed by nasal endoscopy or sinus CT.

Age requirementPatient must be ≥ 12 years of age for initial approval.

Symptom requirementModerate to severe symptoms of nasal congestion, blockage, or obstruction (eg loss of smell, rhinorrhea, or facial pain).

Prior therapyTrial of a nasal corticosteroid spray that was ineffective, contraindicated, or not tolerated is required prior to approval.

PrescriberMust be prescribed by, or in consultation with, an allergist, immunologist, or otolaryngologist for initial approval.

OpenPayer

Tezspire (tezepelumab) Medical Benefit Medication Utilization Policy

Coverage Criteria for Tezepelumab (Tezspire)

Billing and Coding

Provider Requirements and Authorization

Background

Definitions and Clinical Terms