Initial Approval Criteria A. Severe Asthma
(must meet all):
1.
Diagnosis of asthma;
2.
Prescribed by or in consultation with an allergist, immunologist, or
pulmonologist;
3. Age
≥ 12 years;
4.
Member has experienced ≥ 2 exacerbations with in the last 12 months, requiring
any of the following despite adherent use of controller therapy (i.e., medium-
to high-dose inhaled corticosteroid [ICS] plus either a long acting beta-2
agonist [LABA] or leukotriene modifier [LTRA] if LABA
contraindication/intolerance):
a. Oral/systemic
corticosteroid treatment (or increase in dose if already on oral
corticosteroid);
b. Urgent care visit or
hospital admission;
c. Intubation;
5.
Tezspire is prescribed concurrently with an ICS plus either a LABA or LTRA;
6.
Tezspire is not prescribed concurrently with Cinqair®, Dupixent®, Fasenra®,
Nucala®, or Xolair®;
7.
Dose does not exceed 210 mg every 4 weeks.
Approval duration: 6 months
Continued Therapy
A.
Severe Asthma
(must meet all):
1.
Currently receiving medication via Centene benefit or member has previously met
initial approval criteria;
2.
Demonstrated adherence to asthma controller therapy (an ICS plus either a LABA
or LTRA) as evidenced by proportion of days covered (PDC) of 0.8 in the last 6
months (i.e., member has received asthma controller therapy for at least 5 of
the last 6 months);
3.
Member is responding positively to therapy (examples may include but are not
limited to: reduction in exacerbations or corticosteroid dose, improvement in
forced expiratory volume over one second since baseline, reduction in the use of
rescue therapy);
4.
Tezspire is not prescribed concurrently with Cinqair, Dupixent, Fasenra, Nucala,
or Xolair;
5. If
request is for a dose increase, new dose does not exceed 210 mg every 4 weeks.
Approval duration:
6 months or member’s
renewal period, whichever is longer
Codes
Used In This BI:
1)
J2356 – Injection,
Tezepelumab-ekko, 1mg