Medicare AdvantagePrior AuthHigh impact
Tezspire™ (tezepelumab-ekko) (Revised)
Humana·Allergy & Immunology, Pulmonology, ENT (Ear, Nose & Throat) +1 more·Medicare Advantage
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Tezspire (tezepelumab-ekko) prior authorization policy effective November 26, 2025. The policy maintains coverage for severe asthma and chronic rhinosinusitis with nasal polyposis but requires strict prior authorization with specific clinical criteria, including documented exacerbations, maximum tolerated ICS/LABA therapy, and prohibition of concurrent use with other biologic agents (anti-IgE, anti-IL4, anti-IL5). Billing teams must verify prior authorization is obtained before dispensing and ensure claims meet all documented criteria.
Action Required
Before November 26, 2025: (1) Billing team must update pharmacy billing system to require prior authorization for all Tezspire claims on Humana Medicare Advantage plans. (2) Configure system to verify all four criteria are met before claim submission: severe asthma diagnosis with ≥2 exacerbations in 12 months requiring systemic corticosteroids/hospitalization; documentation of maximum tolerated ICS (e.g., mometasone >400mcg or fluticasone >440mcg daily) + LABA therapy; AND no concurrent anti-IgE, anti-IL4, or anti-IL5 agents listed (Xolair, Dupixent, Nucala, Fasenra, Cinqair). (3) For CRSwNP indication: verify daily intranasal corticosteroid use and prior treatment/failure/contraindication with 2 of: Dupixent, Xolair, or Nucala. (4) Prior auth must be approved for initial and renewal plan year duration. (5) Pharmacy staff and providers must document exacerbation history and current medication regimen on all prior auth requests. (6) Claims submitted without approved prior authorization will be denied. Update all relevant team members and communicate with prescribing providers immediately.