Skip to content
The Policy VaultThe Policy Vault

tezepelumab-ekko — Blue Cross Blue Shield of Illinois

severe asthma

Initial criteria

  • 1. ONE of the following: (A) Continuation of therapy and prescriber states patient has been treated with requested agent (not samples) within past 90 days and at risk if therapy changed OR (B) New start meets both of the following:
  • 1. ONE of the following: (A) BOTH of the following: (1) patient has diagnosis of severe asthma AND (2) history of uncontrolled asthma while on asthma control therapy as demonstrated by ONE of: (A) ≥2 systemic corticosteroid bursts in past 12 months, OR (B) serious exacerbations requiring hospitalization/ventilation/ER visits in past 12 months, OR (C) controlled asthma that worsens with steroid taper, OR (D) baseline FEV1 <80% predicted; OR (B) patient has another FDA labeled indication for requested agent and route; OR (C) patient has another indication supported in compendia.
  • 2. If patient has FDA labeled indication, one of: (A) age within FDA labeling, OR (B) supported for use at patient’s age, OR (C) other indication supported in compendia.
  • 2. If diagnosis is severe asthma, ALL of the following:
  • A. ONE of the following: (1) Not currently treated with requested agent AND currently treated with maximally tolerated inhaled corticosteroid (ICS) ≥3 months with adherence 90 days/120 days, OR (2) Currently treated with requested agent AND on adequately dosed ICS ≥3 months with adherence 90 days/120 days, OR (3) Intolerance or hypersensitivity to ICS, OR (4) FDA labeled contraindication to all ICS.
  • B. ONE of the following regarding add-on therapy: (1) Currently treated ≥3 months and adherent 90 days/120 days with one of: LABA, LAMA, LTRA, or theophylline, OR (2) Intolerance or hypersensitivity to LABA, LAMA, LTRA, or theophylline, OR (3) FDA labeled contraindication to all LABA and LAMA.
  • C. Patient will continue asthma control therapy (e.g., ICS, ICS/LABA, LTRA, LAMA, theophylline) in combination with requested agent.
  • 3. Prescriber is specialist (allergist, immunologist, pulmonologist) or consulted such specialist.
  • 4. ONE of the following: (A) not used with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors), OR (B) if used with another immunomodulator, prescribing information allows such use and supportive evidence submitted.
  • 5. Patient does not have FDA labeled contraindications to requested agent.
  • Additional allowance for Ohio fully insured/HIM Shop members: agent approvable if no contraindication and has another FDA-labeled or compendia-supported indication or evidence from two peer-reviewed journal articles supporting use.
  • Compendia allowed: AHFS, DrugDex 1/2a/2b, NCCN 1/2a/2b.
  • Length of approval: BCBSIL 12 months; others 6 months.

Reauthorization criteria

  • 1. Patient previously approved through plan’s prior authorization process.
  • 2. ONE of the following: (A) diagnosis of severe asthma AND BOTH of: (1) improvement/stabilization from baseline with ONE of: increased percent predicted FEV1, decreased ICS dose, decreased need for systemic corticosteroids, or decreased asthma-related hospitalizations/urgent visits; AND (2) currently treated within past 90 days and compliant with asthma control therapy (ICS, ICS/LABA, LTRA, LAMA, theophylline) [chart notes required]; OR (B) other diagnosis with clinical benefit.
  • 3. Prescriber is specialist (allergist, immunologist, pulmonologist) or has consulted one.
  • 4. ONE of: (A) not used with another immunomodulatory agent, OR (B) if combined, prescribing info does not limit concomitant use and supportive evidence submitted.
  • 5. No FDA labeled contraindications.
  • Length of approval: 12 months.

Approval duration

12 months (BCBSIL initial and renewal); other plans initial 6 months, renewal 12 months