Tezspire (tezepelumab-ekko) — United Healthcare
Severe asthma
Initial criteria
- ONE of the following:
- 1) ALL of the following:
- - Patient has been established on therapy with Tezspire under an active UnitedHealthcare medical benefit prior authorization for the treatment of severe asthma
- AND Documentation of positive clinical response to Tezspire therapy
- AND Tezspire is being used as add-on maintenance therapy
- AND Patient is not receiving Tezspire in combination with any of the following for treatment of the same indication:
- • Anti-interleukin 5 therapy [e.g., Cinqair (resilizumab), Fasenra (benralizumab), Nucala (mepolizumab)]
- • Anti-IgE therapy [e.g., Xolair (omalizumab)]
- • Anti-interleukin 4 therapy [e.g., Dupixent (dupilumab)]
- OR
- 2) ALL of the following:
- - Diagnosis of severe asthma
- AND Tezspire is being used as add-on maintenance therapy
- AND Patient is not receiving Tezspire in combination with any of the following for treatment of the same indication:
- • Anti-interleukin 5 therapy [e.g., Cinqair (resilizumab), Fasenra (benralizumab), Nucala (mepolizumab)]
- • Anti-IgE therapy [e.g., Xolair (omalizumab)]
- • Anti-interleukin 4 therapy [e.g., Dupixent (dupilumab)]
Reauthorization criteria
- ALL of the following:
- - Documentation of positive clinical response to Tezspire therapy
- AND Tezspire is being used as add-on maintenance therapy
- AND Patient is not receiving Tezspire in combination with any of the following for treatment of the same indication:
- • Anti-interleukin 5 therapy [e.g., Cinqair (resilizumab), Fasenra (benralizumab), Nucala (mepolizumab)]
- • Anti-IgE therapy [e.g., Xolair (omalizumab)]
- • Anti-interleukin 4 therapy [e.g., Dupixent (dupilumab)]
Approval duration
12 months