| Anthem Blue Cross (HMO, PPO, EPO) |
| Tezspire (tezepelumab-ekko) |
| Drugs for the Lungs : Drugs for Asthma/COPD |
- Step Therapy Applies
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds;
- Asthma (injectable):
Age Requirement: >= 12
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
# of exacerbations in prior year: 2
History of corticosteroid use: >= 3 months
Additional controller failure requirement: 1
Diagnosis Type: Severe
Evidence of Asthma Indicators: 2 of FEV1 < 80% predicted;FEV1 reversibility of >= 12% and 200ml after rescue
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: No
Symptoms Are Not Adequately Controlled: No
Exacerbation Requiring Treatment with Systemic Corticosteroid: No
Use in Combination with Other Injectable Asthma Product: No
Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: No
IgE Level Required: No
Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
Submission of Medical Records Required: Yes
Exclusion Condition(s): Other
Eosinophilic asthma phenotype: No
Injectable ST Required: No
- PA Applies
- Quantity Limit: 1 syringe per 28 day(s).
- Prior Authorization: Asthma (injectable):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
|