Effective Jan. 1, 2024, Tezspire® coverage will shift from a medical benefit to a pharmacy benefit for commercial and individual lines of business.
What’s changing?
Beginning Sep. 1, 2023, coverage for the Tezspire autoinjector pen will be added to the pharmacy benefit as a Tier 4 medication with prior authorization criteria.
Beginning Jan. 1, 2024, Tezspire will no longer be covered under the medical benefit and the prefilled syringe will not be added to the pharmacy benefit. (See table below)
Tezxpire prefilled syringeTezspire autoinjector penWill it be covered beginning September 1 2023?Yes, certain requests for coverage under the medical benefit will be approved. Approved authoruzations will expire December 31, 2023Yes, under the pharmacy benefitWill it be converd beginning January 1, 2024No coverage under the medical or pharmacy benefitYes under the pharmacy benefit
How will this impact our providers?
Tezspire authorizations approved under the medical benefit will now have an end date of Dec. 31, 2023. On Jan. 1, 2024, the authorization we have on file will transfer from the Tezspire prefilled syringe under the medical benefit, to the Tezspire autoinjector pen under the pharmacy benefit. This authorization will be valid until Dec. 31, 2024.
On Jan. 1, 2024, providers will need to submit a new prescription to an approved specialty pharmacy. The approved specialty pharmacy will contact the member to arrange for shipment of their medication. Because Tezspire is currently a limited distribution drug, providers should confirm the approved specialty pharmacy is able to obtain this medication for their patients.
Beginning Jan. 1, 2024, providers will only be reimbursed for the administration of Tezspire. No claims for the drug itself will be reimbursed with dates of service after Dec. 31, 2023.
How will this impact our members?
Beginning Jan. 1, 2024, members will be required to get their prescribed Tezspire autoinjector pen from an approved specialty pharmacy. The pharmacy will coordinate shipment with the members. Members can choose to bring the prescription to their health care provider for administration. Providers will be reimbursed for the administration of Tezspire.
What will the transition process look like?
If your patient is currently receiving Tezspire covered under the medical benefit and you’d like to transition them to the Tezspire autoinjector pen covered under the pharmacy benefit, you can request coverage using a pharmacy drug request form. Be sure to include documentation stating the patient will no longer be receiving doses of Tezspire covered under the medical benefit, along with the date the change will occur. We will transfer the authorization from the medical benefit to the pharmacy benefit on the date requested.
You may request coverage for the Tezspire prefilled syringe under the medical benefit until Dec. 31, 2023. If approved, you will receive a short-term authorization. Members with authorizations approved for coverage under the medical benefit on December 31, 2023, will have authorizations on file for the Tezspire autoinjector pen covered under the pharmacy benefit beginning Jan. 1, 2024. The authorizations will be valid until December 31, 2024.
Criteria for Prior Authorization
The clinical criteria for prior authorization under the pharmacy benefit will match the clinical criteria for coverage under the medical benefit, however providers should use the pharmacy prior authorization form for requests, rather than the medical prior authorization form.
It is our goal to make this transition as seamless as possible for you and your patients, our members. If you have any questions regarding this change in coverage, please reach out.