J2356, Injection, tezepelumab-ekko, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Initial authorization duration for Tezspire is no more than 12 months.
- Verify and document the member's applicable benefit plan, summary plan description, or contract terms.
- Check and document any applicable state regulations that may affect coverage for the service or supply.
- Citation(s) from one or more standard medical reference compendia (as adopted by HHS) showing the use is recognized as safe and effective, when claiming compendia support.
Key Coverage Criteria
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Coverage of any FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by HHS.
- Coverage of an FDA‑approved drug for an off‑label indication when safety and efficacy are confirmed in medical literature by two articles from major peer‑reviewed professional medical journals that present data supporting the proposed off‑label use.
- Add-on maintenance treatment of severe asthma with Tezepelumab-ekko (Tezspire™) when specified clinical criteria are met
- Individual is 12 years of age or older.
- Documented and current use of an inhaled corticosteroid (ICS) in combination with a long-acting beta2-agonist (LABA), leukotriene receptor antagonist (LTRA), theophylline, or long-acting muscarinic antagonist (LAMA) for at least 3 months.
14 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-tezspire, Tezspire (Tezepelumab-Ekko)
RX501.143, Tezepelumab-ekko
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSIL-RX501.143, Tezepelumab-ekko
Related Codes
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