UnitedHealthcare Tezspire Prior Auth Coverage

Coverage Criteria for Tezspire (tezepelumab)

Initial Authorization — Severe Asthma (established under medical benefit)

Covered when ALL of the following are met

Established on Tezspire under UnitedHealthcare medical benefit: Patient has been established on therapy with Tezspire under an active UnitedHealthcare medical benefit prior authorization for the treatment of severe asthma

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Positive clinical response: Documentation of positive clinical response to Tezspire therapy demonstrated by at least one: reduction in the frequency of exacerbations; decreased utilization of rescue medications; increase in percent predicted FEV1 from pretreatment baseline; reduction in severity or frequency of asthma-related symptoms (e.g., wheezing, shortness of breath, coughing)

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Concurrent ICS controller: Tezspire is being used in combination with an inhaled corticosteroid (ICS)-containing controller medication (e.g., fluticasone/salmeterol, budesonide/formoterol, fluticasone furoate/vilanterol)

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No concurrent biologics for same indication: Patient is not receiving Tezspire in combination with anti-interleukin-5, anti-IgE, or anti-interleukin-4 therapy for the same indication

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Prescriber specialty: Prescribed by an allergist, immunologist, or pulmonologist

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Initial Authorization — Severe Asthma (new starts)

Covered when ALL of the following are met

Diagnosis of severe asthma

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Uncontrolled asthma evidence: Asthma is uncontrolled or inadequately controlled as shown by at least one: poor symptom control (ACQ >1.5 or ACT <20); two or more systemic corticosteroid bursts (≥3 days each) in the prior 12 months; asthma-related emergency treatment (ER visit, hospitalization, or unscheduled urgent visit); airflow limitation (post-bronchodilator FEV1 <80% predicted with reduced FEV1/FVC); current dependence on oral corticosteroids

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Required background therapy: Tezspire used in combination with either: a maximally dosed age-appropriate ICS/LABA combination product OR combination therapy of a maximally dosed ICS plus one additional asthma controller medication

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No concurrent biologics:

Reauthorization — Severe Asthma

Covered for reauthorization when ALL of the following are met

Clinical response: Documentation of positive clinical response to Tezspire therapy demonstrated by at least one: reduction in the frequency of exacerbations; decreased utilization of rescue medications; increase in percent predicted FEV1 from pretreatment baseline; reduction in severity or frequency of asthma-related symptoms

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Concurrent ICS controller: Tezspire is being used in combination with an ICS-containing controller medication

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No concurrent biologics: Patient is not receiving Tezspire in combination with anti-interleukin-5, anti-IgE, or anti-interleukin-4 therapy for the same indication

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Initial Authorization — CRSwNP (established under medical benefit)

Covered when ALL of the following are met

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Positive clinical response: Documentation of positive clinical response to Tezspire therapy

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Concurrent intranasal corticosteroids: Patient continues to receive Tezspire as add-on maintenance therapy in combination with intranasal corticosteroids (e.g., fluticasone, mometasone, triamcinolone)

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No concurrent biologics:

Initial Authorization — CRSwNP (new starts)

Covered when ALL of the following are met

Diagnosis of CRSwNP: Diagnosis of chronic rhinosinusitis with nasal polyps defined by: two or more symptoms for longer than 12 weeks (nasal mucopurulent discharge; nasal obstruction/blockage/congestion; facial pain/pressure/fullness; reduction or loss of sense of smell); one endoscopic or CT finding (purulent mucus/edema in middle meatus or ethmoid, polyps, or radiographic mucosal thickening/opacification); and either bilateral nasal polyposis or prior surgical removal of bilateral nasal polyps

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Severity/prior interventions: Patient has required prior sinus surgery; OR systemic corticosteroids for CRSwNP in the previous 2 years; OR has been unable to obtain symptom relief after trial of two of: nasal saline irrigations, intranasal corticosteroids, or antileukotriene agents

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Concurrent intranasal corticosteroids: Patient will receive Tezspire as add-on maintenance therapy in combination with intranasal corticosteroids (e.g., fluticasone, mometasone, triamcinolone)

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Reauthorization — CRSwNP

Covered for reauthorization when ALL of the following are met

Clinical response: Documentation of positive clinical response to Tezspire therapy

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Concurrent intranasal corticosteroids: Patient will continue to receive Tezspire as add-on maintenance therapy in combination with intranasal corticosteroids (e.g., fluticasone, mometasone, triamcinolone)

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No concurrent biologics: Patient is not receiving Tezspire in combination with anti-interleukin-5, anti-IgE, or anti-interleukin-4 therapy for the same indication

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Tezspire (tezepelumab) is not indicated for relief of acute bronchospasm or status asthmaticus. This limitation of use means Tezspire should not be used for immediate treatment of acute asthma exacerbations or life‑threatening bronchospasm and is intended only as add‑on maintenance therapy for eligible patients.

The program described in this policy applies to the prefilled pen formulation for self‑administration. Other formulations — specifically the single‑dose vial and pre‑filled syringe intended for administration by a healthcare professional — are typically covered under the medical benefit; providers should refer to the UnitedHealthcare Medical Benefit Drug Policy for Tezspire for coverage details. Additionally, UnitedHealthcare may use automated approval logic based on prior claims/medication history, diagnosis codes (ICD‑10), and claim rules, and supply limitations may apply.

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Coding and Clinical Score Thresholds

Cross-referencemixed

Reference to medical benefit drug policy for other formulations (single-dose vial and pre-filled syringe)

Asthma control scores — ACQ > 1.5 or ACT < 20

ACQ thresholdAsthma Control Questionnaire (ACQ) score consistently > 1.5

ACT thresholdAsthma Control Test (ACT) score consistently < 20

Source contextUsed as criteria for classification of asthma as uncontrolled or inadequately controlled

Provider Actions, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for Tezspire prefilled pen under the UnitedHealthcare medical benefit. Approval requires meeting the stated clinical criteria for the applicable indication (severe asthma or chronic rhinosinusitis with nasal polyps) and a prescription from an appropriate specialist.

Affected product: Tezspire (tezepelumab) prefilled pen and single-dose vial when billed under the medical benefit
Prescribers: Allergist, Immunologist, Pulmonologist, or Otolaryngologist (for CRSwNP)

Note

Automated Prior Authorization Allowance

UnitedHealthcare may use automated prior authorization logic to approve initial or reauthorization requests when prior claim/medication history, diagnosis codes (ICD-10), and related claim logic support the request. Ensure submitted claims and diagnosis coding accurately reflect the indication and prior therapy to enable automated approval.

Automated approvals rely on prior claims/medication history and accurate ICD-10 diagnosis coding

Background — Drug and Indications

Tezspire (tezepelumab‑ekko) is an add‑on maintenance biologic indicated for treatment of patients aged 12 years and older with severe asthma or inadequately controlled chronic rhinosinusitis with nasal polyps (CRSwNP). It is intended for maintenance therapy rather than acute rescue therapy and is available in multiple formulations; this policy focuses on the prefilled pen for self‑administration while other formulations for administration by a healthcare professional are typically managed under the medical benefit.

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Definitions and Clinical Thresholds

Tezspire — key product definition and formulation note

ProductTezspire (tezepelumab-ekko), a biologic add-on maintenance treatment for patients aged ≥12 years

Formulation in this programPrefilled pen for self-administration (pharmacy program applies to prefilled pen)

Other formulationsSingle-dose vial and pre-filled syringe are typically covered under the medical benefit (administration by healthcare professional)

Uncontrolled/inadequately controlled asthma — definition

Primary control thresholdsUncontrolled/inadequately controlled defined by at least one: ACQ > 1.5 or ACT < 20

Steroid burstsTwo or more systemic corticosteroid bursts (≥3 days each) in the previous 12 months

OpenPayer

Tezspire (tezepelumab) — Prior Authorization and Medical Necessity (prefilled pen)

Coverage Criteria for Tezspire (tezepelumab)

Coding and Clinical Score Thresholds

Provider Actions, Documentation, and Denial Risks

Background — Drug and Indications

Definitions and Clinical Thresholds