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:
-
The individual must meet FDA-approved label for use (e.g., use outside of studied population will be considered investigational);
and
-
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 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 individual has previously been approved for tezepelumab-ekko (Tezspire) through Blue Cross Blue Shield of North Dakota's precertification process;
and
-
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;
and
- Must be prescribed by, or in consultation with, a pulmonologist or allergist/immunologist.
Continuation Authorization: 12 months
The use of tezepelumab-ekko (Tezspire) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
