Summary
Effective December 1, 2026, BlueCross BlueShield of Tennessee's tezepelumab-ekko (Tezspire) medical policy sets coverage criteria for severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) in members 12 years of age and older. Authorization of 6 months may be granted for severe asthma and for CRSwNP when the listed criteria are met, and authorization of 12 months may be granted for continuation when the member shows improvement or a positive clinical response. All other indications are considered experimental/investigational and not medically necessary.
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What to do
Action · 9 steps
01Before December 1, 2026: Submit the documentation needed to start prior authorization review.
02For initial asthma requests, send chart notes, medical record documentation or claims history showing previous medications tried, including drug, dose, frequency and duration.
03For initial CRSwNP requests, send chart notes or medical record documentation of nasal endoscopy, anterior rhinoscopy or computed tomography (CT) details such as polyp location and size, the Meltzer Clinical Score or the endoscopic nasal polyp score (NPS) where applicable, and previous medications tried with drug, dose, frequency and duration, or the clinical reason to avoid therapy if therapy is not advisable.
04For continuation requests, send chart notes or medical record documentation of improved asthma control for asthma, and of a positive clinical response for CRSwNP.
05The medication must be prescribed by or in consultation with an allergist/immunologist or pulmonologist for asthma, and an allergist/immunologist or otolaryngologist for CRSwNP.
06Members must keep using maintenance asthma treatment (e.g., inhaled corticosteroid and an additional controller) with the requested medication, and members with CRSwNP must keep using a daily intranasal corticosteroid unless contraindicated or not tolerated.
07Do not use it concomitantly with any other biologic or targeted synthetic drug for the same indication.
08If the member is a current smoker or vaper, counsel them on the harmful effects of smoking and vaping on pulmonary conditions and on available cessation options.
09Quantity limit: 210 mg subcutaneously every 4 weeks for ages 12 and older for asthma and for CRSwNP.
Original notice
Tezepelumab-ekko (Tezspire®)
bcbst.com · Always check the source before changing claims.