Tezspire (tezepelumab-ekko) — provider-administered therapy
Customize your policy alerts
Sign up for sierra health and life Policy 2026D0110K alerts
Get alerted when Policy 2026D0110K changes without checking for updates manually.
Monitor payer policy activity
Covers clinical medical benefit criteria for provider-administered Tezspire (tezepelumab-ekko) as add-on maintenance therapy for severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP); affects providers submitting medical benefit prior authorizations for Sierra Health and Life members. (Part 1 of 3 — partial document.)
Replaced language indicating 'the [listed] criteria [must be met] for continuation of therapy' with 'authorization for continued use will be approved for patients currently on Tezspire for the treatment of severe asthma based on the [listed] criteria'.
Added detailed initial therapy and continuation criteria for Tezspire for CRSwNP including diagnostic requirements, prior therapy trials, concomitant therapy restrictions, prescriber specialty, dosing per FDA labeling, and authorization duration (initial and reauthorization no more than 12 months).
ICD-10 diagnosis codes J31.0, J32.0, J32.1, J32.2, J32.3, J32.4, J32.8, J32.9, J33.0, J33.1, J33.8, and J33.9 were added to the applicable codes list.
Background, Clinical Evidence, FDA, and References sections were updated to reflect the most current information.
Previous policy version 2025D0110J was archived.
Coverage Criteria for Tezspire (tezepelumab-ekko)
inv-01: Severe Asthma — Initial Therapy — Covered when ALL of the following are met
Covered when ALL of the following are met
Indicators include ACQ > 1.5 or ACT < 20; two or more systemic steroid bursts in prior 12 months; asthma-related emergency care; airflow limitation; maintenance oral corticosteroid dependence.
inv-02: Severe Asthma — Continuation Therapy — Reauthorization/Continuation of Care — all elements required
Reauthorization/Continuation of Care — all elements required
inv-03: CRSwNP — Initial Therapy — Covered when ALL of the following are met
Covered when ALL of the following are met
inv-04: CRSwNP — Continuation Therapy — Reauthorization/Continuation of Care — all elements required
Reauthorization/Continuation of Care — all elements required
inv-05: Initial Therapy (CRSwNP) — Covered for CRSwNP when ALL of the following are met:
Covered for CRSwNP when ALL of the following are met:
inv-06: Continuation Therapy (CRSwNP) — Continuation/reauthorization covered when ALL of the following are met:
Continuation/reauthorization covered when ALL of the following are met:
inv-07: Clinical Evidence (Severe Asthma) — Severe asthma coverage context (informational clinical evidence supporting use):
Severe asthma coverage context (informational clinical evidence supporting use):
Not an authorization algorithm but provides supportive evidence for coverage decisions.
Concurrent administration of Tezspire (tezepelumab-ekko) with other biologic therapies for the same clinical indication is not permitted. Specifically, patients must not receive Tezspire in combination with anti‑interleukin‑5 therapies (for example, reslizumab, benralizumab, mepolizumab), anti‑IgE therapy (omalizumab), or anti‑interleukin‑4 therapy (dupilumab) when treating the same condition. This restriction applies to both initial therapy and continuation/reauthorization determinations.
The policy explicitly requires that Tezspire not be used in combination with anti‑IL‑5, anti‑IgE, or anti‑IL‑4 therapies for the same indication. Requests for coverage that propose concurrent use for the same diagnosis (e.g., severe asthma or CRSwNP) should be denied or considered not consistent with the coverage criteria unless clear documentation demonstrates distinct, non‑overlapping indications supported by the member's benefit plan.
This policy is informational and reflects UnitedHealthcare standard benefit plan interpretation; providers must verify the member’s specific benefit plan and any applicable federal or state mandates. In the event of conflict, the member‑specific benefit plan document governs, and plan‑level exclusions or limits may apply beyond the criteria described here.
Tezspire is indicated as add‑on maintenance therapy for patients with uncontrolled or inadequately controlled asthma. The policy states Tezspire is not indicated when asthma is controlled (i.e., the patient does not meet the documented uncontrolled criteria such as ACQ > 1.5 or ACT < 20, ≥2 systemic steroid bursts in the prior 12 months, asthma‑related emergency treatment, airflow limitation, or maintenance oral corticosteroid dependence). For continuation/reauthorization, the patient must show documentation of a positive clinical response and continue concomitant ICS‑containing maintenance therapy per the coverage requirements.
Initial therapy requests for CRSwNP or severe asthma that do not meet the documented diagnostic criteria, prior therapy requirements, or required concomitant controller therapy should be considered not meeting medical necessity. For CRSwNP, initial authorization requires documented diagnostic evidence (symptoms >12 weeks, endoscopy or CT findings, bilateral nasal polyposis or prior bilateral polypectomy) and history of prior sinus surgery or systemic corticosteroid use within 2 years or failed trials of two specified classes; absence of these elements may justify denial of initial therapy requests.
No additional not‑medically‑necessary conditions are explicitly stated in this excerpt beyond those implied by failure to meet the stated criteria. Operationally, requests are considered not medically necessary when they lack required diagnostic documentation, prior therapy trials, concomitant intranasal or inhaled corticosteroid therapy, or if they propose concurrent use with the excluded biologics. Always confirm member‑specific plan language and mandates before making a final medical necessity determination.
Coding and Diagnosis Codes
| J2356 | Injection, tezepelumab-ekko, 1 mg. |
| J31.0 | Chronic rhinitis. |
| J32.0 | Chronic maxillary sinusitis. |
| J32.1 | Chronic frontal sinusitis. |
| J32.2 | Chronic ethmoidal sinusitis. |
| J32.3 | Chronic sphenoidal sinusitis. |
| J32.4 | Chronic pansinusitis. |
| J32.8 | Other chronic sinusitis. |
| J32.9 | Chronic sinusitis, unspecified. |
| J33.0 | Polyp of nasal cavity. |
| J33.1 | Polypoid sinus degeneration. |
| J31.0 | |
| J32.0 | |
| J32.1 | |
| J32.2 | |
| J32.3 | |
| J32.4 | |
| J32.8 | |
| J32.9 | |
| J33.0 | |
| J33.1 |
| J31.0 | Chronic rhinitis |
| J32.0 | Chronic maxillary sinusitis |
| J32.1 | Chronic frontal sinusitis |
| J32.2 | Chronic ethmoidal sinusitis |
| J32.3 | Chronic sphenoidal sinusitis |
| J32.4 | Chronic pansinusitis |
| J32.8 | Other chronic sinusitis |
| J32.9 | Chronic sinusitis, unspecified |
| J33.0 | Polyp of nasal cavity |
| J33.1 | Polypoid sinus degeneration |
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization Required
Prior authorization is required. Initial approvals will be limited to no more than 12 months; reauthorization/continuation approvals will also be for no more than 12 months. Providers must verify member-specific benefits and any applicable federal or state mandates before relying on this policy; the member-specific benefit plan document governs in the event of a conflict.
- Initial authorization: ≤ 12 months
- Reauthorization/continuation: ≤ 12 months
- Check member-specific benefit plan and applicable mandates before submitting
Required Documentation for CRSwNP Initial Authorization
For CRSwNP initial authorization, documentation must show the diagnosis and objective findings consistent with chronic rhinosinusitis with nasal polyps and prior therapy attempts. Required documentation includes symptom duration >12 weeks with two or more key symptoms and nasal endoscopy and/or sinus CT findings (e.g., purulent mucus or edema in the middle meatus/ethmoid regions, polyps in the nasal cavity or middle meatus, or mucosal thickening/partial or complete opacification on imaging).
- Two or more symptoms >12 weeks: nasal mucopurulent discharge; nasal obstruction/blockage/congestion; facial pain/pressure/fullness; reduction or loss of smell
- Objective finding: nasal endoscopy and/or sinus CT demonstrating purulence/edema, polyps, or mucosal thickening/opacification
Prior Therapy Requirements for CRSwNP
Prior therapy requirements for CRSwNP must be documented. Patient must have had an inadequate response to previous therapies, which may include prior sinus surgery or systemic corticosteroids in the prior 2 years, or failure to obtain symptom relief after trial of two classes of agents.
- Prior sinus surgery OR systemic corticosteroids (e.g., prednisone, methylprednisolone) for CRSwNP in past 2 years
- OR inadequate response after trial of two classes among: nasal saline irrigations; intranasal corticosteroids (e.g., fluticasone, mometasone, triamcinolone); antileukotriene agents (e.g., montelukast, zafirlukast, zileuton)
Required Clinical Response Documentation for Reauthorization
For reauthorization/continuation (both severe asthma and CRSwNP), documentation of positive clinical response is required. Examples of acceptable evidence include reduced exacerbation frequency, decreased rescue medication use, increased percent predicted FEV1 from pretreatment baseline, or reduced severity/frequency of disease-related symptoms.
- Reduction in frequency of exacerbations
- Decreased utilization of rescue medications
- Increase in % predicted FEV1 from pretreatment baseline
- Reduction in severity or frequency of disease-related symptoms (e.g., wheezing, shortness of breath, coughing)
Triggers and Potential Denial Reasons
Requests may be denied if required diagnostic criteria or documentation are not provided, if the drug is not being used as add-on maintenance therapy, or if required prior therapy requirements for CRSwNP are not met. Requests may also be denied when Tezspire is prescribed concurrently with disallowed biologic therapies for the same indication.
- Denial triggers: missing required diagnosis or objective findings for CRSwNP
- Denial triggers: therapy not documented as add-on maintenance
- Denial triggers: prior therapy requirements for CRSwNP not met
- Denial triggers: concurrent use with anti-IL-5, anti-IgE, or anti-IL-4 therapies for the same indication (e.g., reslizumab, benralizumab, mepolizumab, omalizumab, dupilumab)
Verify Member-Specific Plan and Use of Third-Party Tools
Before submitting an authorization request, providers must check the member-specific benefit plan document and any applicable federal or state mandates. Failure to reference the member-specific plan may result in coverage issues. UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in administering benefits.
- Member-specific benefit plan governs in event of conflict with this policy
- Verify member-specific benefits and mandates prior to relying on this policy
- UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in administration
Background and Clinical Context
Asthma is a chronic inflammatory airway disease; an estimated portion of patients (commonly cited as 5–10%) have severe disease requiring specialty biologic therapy. Chronic rhinosinusitis with nasal polyps (CRSwNP) is a persistent inflammatory condition of the nasal passages and paranasal sinuses characterized by polyps and symptoms lasting more than 12 weeks. Standard care for CRSwNP includes intranasal corticosteroids, systemic corticosteroids, and sinus surgery when indicated. Tezspire is a human monoclonal antibody that binds thymic stromal lymphopoietin (TSLP), reducing downstream airway and mucosal inflammation and providing an add‑on maintenance option across asthma phenotypes and for CRSwNP when patients meet the policy criteria.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.