Tezspire — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR meets new-start criteria.
• For new starts: The patient has a diagnosis of severe asthma AND a history of uncontrolled asthma while on asthma control therapy as shown by ANY of the following: (A) ≥2 courses of systemic corticosteroids in past 12 months; (B) hospitalization, mechanical ventilation, or ER/urgent care visit in past 12 months; (C) controlled asthma that worsens when corticosteroids tapered; (D) baseline FEV1 < 80% predicted.
• OR the patient has another FDA labeled indication for the requested agent and route of administration OR has a compendia-supported indication.
• If the indication is FDA-approved: The patient's age is within FDA labeling OR there is support for off-label age use.
• If severe asthma: The patient must meet ALL of the following inhaled therapy requirements:
• ONE of the following: (A) is not currently treated with requested agent AND has used a maximally tolerated inhaled corticosteroid (ICS) ≥3 months with ≥90 days adherence in past 120 days [chart notes required]; OR (B) is currently treated with requested agent AND has been treated and adherent to adequately dosed ICS for ≥3 months; OR (C) has intolerance/hypersensitivity or contraindication to ALL ICS.
• AND ONE of the following: (A) treated ≥3 months and adherent to ONE of: LABA, LAMA, LTRA, theophylline [chart notes required]; OR (B) has intolerance/hypersensitivity to these; OR (C) FDA labeled contraindication to ALL LABA and LAMA.
• AND The patient will continue asthma control therapy (e.g., ICS, ICS/LABA, LTRA, LAMA, theophylline) in combination with the requested agent.
• The prescriber is a specialist (e.g., allergist, immunologist, pulmonologist) or has consulted with one.
• The patient will NOT use Tezspire with another immunomodulatory agent (TNF inhibitors, JAK inhibitors, IL-4 inhibitors) unless BOTH of the following: no labeling limitation AND evidence supports combination therapy.
• The patient does NOT have any FDA labeled contraindications to Tezspire.
• Compendia Allowed: AHFS, DrugDex 1, 2a, or 2b, or NCCN 1, 2a, or 2b.
• Alternate coverage route: If member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND all of the following: (A) no FDA labeled contraindications AND (B) indication is FDA labeled OR compendia-supported OR supported by ≥2 peer‑reviewed journal articles showing efficacy with approved study design.

Reauthorization criteria

• The patient was previously approved through the plan’s PA process.
• For severe asthma: continued clinical benefit evidenced by ANY of (A) increase in percent predicted FEV1; (B) decrease in ICS dose required; (C) decrease in systemic corticosteroid use; (D) reduced hospitalizations, need for mechanical ventilation, ER/urgent care visits.
• The patient is currently treated within the past 90 days and compliant with asthma control therapy (e.g., ICS, ICS/LABA, LTRA, LAMA, theophylline) [chart notes required].
• For indications other than severe asthma: the patient continues to have clinical benefit.
• The prescriber is a specialist (e.g., allergist, immunologist, pulmonologist) or has consulted with one.
• The patient will NOT use the requested agent with another immunomodulatory agent unless BOTH: no labeling limitation AND support for combination therapy.
• The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

6–12 months