Medicare AdvantagePrior AuthMedium impact
MA08.144c, Tezepelumab-ekko (Tezspire®)
Independence Blue Cross·Pulmonology, Allergy & Immunology, Pharmacy·Pharmacy
Effective date
Jun 15, 2026
We identified it
Jun 19, 2026
Summary
MA08.144c updates medical necessity criteria for Tezepelumab-ekko (Tezspire®), a biologic asthma treatment. This recent policy change affects how prior authorization and coverage decisions are made for this pharmacy benefit under Medicare Advantage plans. Billing teams must ensure claims align with the new medical necessity requirements to avoid denials.
Action Required
By June 15, 2026: Billing team must review and implement the updated medical necessity criteria for Tezepelumab-ekko (Tezspire®) in your prior authorization workflows and billing system. Coordinate with providers and clinical staff to ensure all documentation submitted with claims meets the new criteria outlined in MA08.144c. Update any internal guidelines, prior auth templates, and claim submission processes to reflect these changes. Verify that submitted claims include required medical necessity documentation per this policy. Claims submitted without compliance to the new criteria will be denied by Medicare Advantage plans.