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Prior Authorization Criteria Added for Tezepelumab-ekko (Tezspire) Procedure Code J2356 Effective August 1, 2022

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after August 1, 2022, prior authorization criteria will be added for tezepelumab-ekko (Tezspire) procedure code J2356.

Prior Authorization

Prior authorization for tezepelumab-ekko (Tezspire) may be considered as add-on maintenance for severe asthma:

  • For clients who are 12 years of age or older.
  • For clients who have a diagnosis of severe asthma (diagnosis codes J4550 and J4551).
  • Not used as a single or primary therapy.
  • For clients who are currently on the following as regular treatment for severe asthma and are compliant on the therapy:
  • Medium or high-dose inhaled corticosteroid therapy, and
  • An additional asthma controller
  • Not in combination with anti-IgE, anti-IL4, or anti-IL5 monoclonal antibody agents (benralizumab, omalizumab, mepolizumab, reslizumab, dupliumab).
  • Not administered concurrently with live attenuated vaccination.

Clients with preexisting helminth infections should be treated prior to receiving tezepelumab-ekko (Tezspire) therapy:

  • If there is active helminth infection, the client should be treated with anti-helminth treatment.
  • If there is no response, treatment with tezepelumab-ekko (Tezspire) should be discontinued until the parasitic infection resolves.

Continuation of Therapy Requirements

Therapy may be continued if the following criteria are met:

  • The client continues to meet the initial authorization approval for tezepelumab-ekko (Tezspire) and has not had any hypersensitivity reactions or unacceptable adverse events, such as helminth infection.
  • The client has experienced positive clinical response to therapy as demonstrated by no increase in asthma exacerbations or improvement in asthma symptoms.

For more information, call the TMHP Contact Center at 800-925-9126.