Tezspire (tezepelumab) Medical Benefit Medication Utilization Policy
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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.
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:
Initial Therapy - Chronic rhinosinusitis with nasal polyps
Covered when ALL of the following are met:
Continuation Therapy - Severe asthma
Covered when ALL of the following are met:
Continuation Therapy - CRSwNP
Covered when ALL of the following are met:
Use of tezepelumab in combination with another targeted immunomodulator product used for asthma is not permitted. The prescriber must attest that the patient will not receive concomitant targeted asthma immunomodulator therapy as a condition of coverage.
Billing and Coding
| J2356 | Injection, tezepelumab-ekko, 1 mg |
Provider Requirements and 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 / 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
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
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
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