Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
The use of tezepelumab-ekko (Tezspire) may be considered medically necessary when ALL of the following criteria are met:
- Must be prescribed by, or in consultation with, a pulmonologist or allergist/immunologist; and
- The individual must have had at least one (1) asthma exacerbation requiring use of oral corticosteroids in previous year despite continued compliant use of a moderate to high dose inhaled steroid in combination with a long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA) as evidenced by paid claims or pharmacy printouts.
Initial Authorization: Three (3)months
Reauthorization Criteria
Continuation of therapy with tezepelumab-ekko (Tezspire) may be considered medically necessary when the following are met:
- The prescriber must provide documentation showing that the individual has achieved a significant reduction in asthma exacerbations and utilization of rescue medications since treatment initiation.
Continuation Authorization: 12 months
Tezepelumab-ekko (Tezspire) for any other indication not listed within this policy will be considered experimental/investigational and, therefore, not-covered. Scientific evidence does not support its efficacy or safety for any other indications.
Procedure Codes
