CurrentUnitedHealthcarePolicy CSOH2026D0110.C

Tezspire (Tezepelumab-Ekko) — medical benefit (Ohio only)

Covers medical-benefit administration of Tezspire (vial and pre-filled syringe) for UnitedHealthcare Community Plan members in Ohio; prefilled pen for self-administration is covered under the pharmacy benefit. Applies when requests are evaluated under Ohio Administrative Code 5160-1-01 and delegates clinical criteria to the Ohio Medicaid Unified Preferred Drug List.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyTezspire (Tezepelumab-Ekko) — medical benefit (vial & pre-filled syringe)

Policy CodePolicy CSOH2026D0110.C

Change TypeRoutine reviewno content changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests that meet the Ohio Medicaid Unified Preferred Drug List clinical criteria and reference applicable Ohio Administrative Code requirements.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

Ohio-onlystate applicability

vial & syringemedical benefit formulations

prefilled penpharmacy benefit formulation

Ohio PDLcoverage source

Coverage Criteria — Tezspire (tezepelumab-ekko)

Medical necessity (delegated to Ohio PDL)

Tezspire (vial and pre-filled syringe) is considered medically necessary when it meets the Ohio Department of Medicaid Unified Preferred Drug List Criteria and applicable Ohio Administrative Code requirements.

Medical necessity per Ohio PDL and OAC: Provider must meet Ohio Department of Medicaid Unified Preferred Drug List Criteria and any relevant Ohio Administrative Code (5160-1-01) requirements for requests not expressly covered or when quantity limits apply.

Policy delegates specific clinical criteria to the Ohio Department of Medicaid Unified Preferred Drug List; medical-benefit formulations are vial and pre-filled syringe for administration by a healthcare professional.

The pre-filled pen for self-administration of Tezspire (tezepelumab‑ekko) is not covered under the medical benefit. Requests for that formulation should be handled through the pharmacy benefit (prefilled pen obtained via pharmacy). Medical-benefit coverage and this policy apply to the vial and pre-filled syringe formulations intended for administration by a healthcare professional.

This policy underwent a routine review effective 01/01/2026 and the previous policy version (CSOH2025D0110.B) was archived. There are no explicit “not medically necessary” statements added or removed as part of this revision; the document notes no content changes associated with the routine review.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyTezspire (Tezepelumab-Ekko) — medical benefit (vial & pre-filled syringe)

Policy CodePolicy CSOH2026D0110.C

Change TypeRoutine reviewno content changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests that meet the Ohio Medicaid Unified Preferred Drug List clinical criteria and reference applicable Ohio Administrative Code requirements.

SourceLink

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Step	Requirement
1	Any step therapy requirements are defined by the Ohio Department of Medicaid Unified Preferred Drug List Criteria; refer to the Ohio PDL for specific step/previous‑therapy requirements for tezepelumab.

Provider Actions and Prior Authorization Considerations

Denial Risk

Denial Risk When OAC Criteria Not Met

Requests that do not meet Ohio Administrative Code (OAC) 5160-1-01 criteria or that are stated as unproven or subject to coverage/quantity limits are at risk for denial. Providers should ensure documentation demonstrates compliance with applicable OAC requirements before submission.

Applies to services stated as unproven or with coverage/quantity limits
Medical necessity will be evaluated under OAC 5160-1-01

Documentation Required

Reference Governing Coverage Rules

When requesting coverage or prior authorization, providers must reference and follow governing coverage rules, including federal law, the Ohio Administrative Code (OAC), and any applicable contractual benefit plan terms. In case of conflict, federal, state (OAC), or contractual requirements govern over this policy.

Verify federal, state (OAC), and contractual plan terms before submission
This policy is informational and may be superseded by governing rules

Step Therapy

Step Therapy per Ohio PDL

Step therapy or other utilization controls for this drug may be required per the Ohio Department of Medicaid Unified Preferred Drug List (PDL). Providers must consult the Ohio PDL for any step therapy, prior authorization prerequisites, or sequencing requirements before requesting coverage under the medical benefit.

Follow Ohio PDL step therapy requirements where applicable
Check PDL for specific prior authorization or sequencing rules

Prior Authorization

Ohio Medicaid Medical-Benefit Review

Medical-benefit administration for drugs referenced in this policy is subject to review and criteria from the Ohio Department of Medicaid. Providers should ensure authorizations and supporting documentation align with Ohio Medicaid medical-benefit rules.

Medical-benefit administration may be reviewed by Ohio Department of Medicaid
Ensure documentation aligns with Ohio Medicaid criteria

Formulation Definitions

inv-09: vial and pre-filled syringe for administration by a healthcare professional — medical-benefit formulations

FormulationVial and pre-filled syringe for administration by a healthcare professional (medical benefit)

Coverage stanceMedical-benefit formulations covered when medical necessity is met per Ohio Department of Medicaid Unified Preferred Drug List Criteria

Site of careAdministration by a healthcare professional (e.g., infusion center)

Assessment referenceMedical necessity determinations reference Ohio Department of Medicaid Unified Preferred Drug List Criteria

ApplicabilityApplies to members in Ohio under this Medical Benefit Drug Policy

inv-10: pre-filled pen for self-administration — pharmacy-benefit formulation

FormulationPre-filled pen for self-administration (pharmacy benefit)

Coverage stanceNot covered under the medical benefit; obtained through the pharmacy benefit

Assessment referencePharmacy-benefit dispensing follows applicable pharmacy coverage rules and Ohio PDL guidance where relevant

Patient useIntended for self-administration by the patient

ApplicabilityApplies to members in Ohio under this policy context

OpenPayer

Tezspire (Tezepelumab-Ekko) — medical benefit (Ohio only)

Coverage Criteria — Tezspire (tezepelumab-ekko)

Initial Therapy (per Ohio PDL)

Step Therapy Requirements

Provider Actions and Prior Authorization Considerations

Site of Care — Administration Setting

Formulation Definitions

Background