Provider Alert! Tezspire (Tezepelumab-ekko) Update Effective July 1Texas Children's Health Plan
Date: June 28, 2021
Attention: All Providers
Effective Date: July 1, 2022
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons.
Providers should direct questions to their Provider Relations Liaison or send an email inquiry to the Provider Relations Department at email@example.com.
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that beginning July 1, 2022, Tezspire (procedure J2356) will become a benefit of Medicaid and CHIP. The Health and Human Services Commission (HHSC) will require prior authorization for Tezspire beginning August 1, 2022. Tezspire is a monoclonal antibody indicated for the treatment of severe asthma as add-on maintenance. It has been U.S. Food and Drug Administration (FDA) approved for patients aged 12 years and older.
How this impacts providers: Prior authorization approval for Tezspire therapy will be considered once all the following criteria are met:
- The client is 12 years of age or older.
- The client has a confirmed diagnosis of severe asthma (diagnosis code: J45.50 and J45.51).
- The client uses Tezspire as an add-on maintenance therapy.
- The client is currently on the following as a regular treatment for severe asthma and is compliant with the therapy:
- Medium or high-dose inhaled corticosteroid therapy, and
- An additional asthma controller
- Any client with pre-existing helminth infections should be treated before receiving Tezspire (tezepelumab-ekko) therapy.
- Tezspire (tezepelumab-ekko) should not be administered concurrently with live attenuated vaccination.
For renewal or continuation therapy
- The client continues to meet the initial authorization approval criteria for Tezspire.
- The client has not had any hypersensitivity reactions or unacceptable adverse events like helminth infection due to therapy.
- The client experienced a positive clinical response to therapy, as demonstrated by no increase in asthma exacerbations or improvement in asthma symptoms.
Note: Tezspire should not be used to relieve acute bronchospasm or status asthmaticus, and it may not be used in combination with anti-IgE, anti_IL4, or anti-IL5 monoclonal antibody agents (i.e., benralizumab, omalizumab, mepolizumab, reslizumab, dupilumab, etc.)
Next steps for providers: Providers should refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider Procedure Manual for more details on the clinical policy and prior authorization requirements. Prescribers should also adjust their prescribing patterns accordingly and share this update with their staff.
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
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