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tezepelumab-ekko — Blue Cross Blue Shield of Montana

severe asthma

Initial criteria

  • 1. ONE of the following: (A) The requested agent is eligible for continuation of therapy AND prescriber states patient has been treated with requested agent within past 90 days and is at risk if therapy is changed OR (B) 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: - ≥2 courses of systemic corticosteroids within past 12 months OR - serious asthma exacerbations requiring hospitalization/mechanical ventilation/ER or urgent care visit within past 12 months OR - controlled asthma worsening when corticosteroid doses tapered OR - baseline FEV1 < 80% predicted; OR (B) Patient has another FDA labeled indication for the requested agent and route of administration.
  • 2. If patient has an FDA labeled indication, ONE of: (A) Patient’s age is within FDA labeling for requested indication OR (B) There is support for using agent for patient’s age OR (C) Patient has another indication supported in compendia for the requested agent and route of administration.
  • 2. If patient has diagnosis of severe asthma, then ALL of the following: (A) ONE of the following: patient not currently treated with requested agent AND currently treated with maximally tolerated inhaled corticosteroid for ≥3 months with adherence ≥90 of past120 days OR patient currently treated with requested agent AND (A) currently treated with ICS for ≥3 months adequately dosed and adherent for 90/120 days OR (B) currently treated with maximally tolerated ICS ≥3 months and adherent 90/120 days OR intolerance/hypersensitivity/contraindication to all ICS; AND (B) ONE of following: currently treated ≥3 months and adherent 90/120 days with LABA or LAMA or LTRA or theophylline OR intolerance/hypersensitivity to these OR contraindication to all LABA and LAMA; AND (C) will continue asthma control therapy in combination with requested agent.
  • 3. Prescriber is specialist (allergist, immunologist, pulmonologist) or has consulted with one.
  • 4. ONE of the following: (A) Will NOT be used with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) Will be used in combination AND (1) prescribing information does NOT limit concomitant use AND (2) support for combination therapy provided (clinical trials, phase III studies, guidelines).
  • 5. Patient does NOT have any FDA labeled contraindications to requested agent.
  • Compendia allowed: AHFS, DrugDex 1,2a,2b, or NCCN 1,2a,2b.
  • Length of approval: BCBSIL 12 months; all other plans 6 months.
  • Additional approval path: Member resides in Ohio AND plan is Fully Insured or HIM Shop AND (A) no FDA labeled contraindications AND (B) ONE of: (1) another FDA labeled indication OR (2) indication supported in compendia OR (3) prescriber submits two peer-reviewed journal articles supporting use.

Reauthorization criteria

  • 1. Previously approved for requested agent through plan’s Prior Authorization process.
  • 2. ONE of following: (A) Diagnosis of severe asthma AND BOTH: (1) Improvement or stabilization from baseline shown by ONE of: increase in FEV1 OR decrease in ICS dose OR decrease in systemic corticosteroid use OR decrease in hospitalizations/mechanical ventilation/urgent care or ER visits; AND (2) Currently treated within past 90 days and compliant with asthma control therapy (ICS, ICS/LABA, LTRA, LAMA, theophylline); OR (B) Diagnosis other than severe asthma AND clinical benefit with requested agent.
  • 3. Prescriber is specialist (allergist, immunologist, pulmonologist) or has consulted with one.
  • 4. ONE of following: (A) Will NOT be used with another immunomodulatory agent OR (B) Will be used in combination AND (1) prescribing info does NOT limit concomitant use AND (2) support for combination therapy provided.
  • 5. Patient does NOT have any FDA labeled contraindications.
  • Length of approval: 12 months.

Approval duration

initial 6-12 months; renewal 12 months