In the Hetlioz group, 29% of patients (n = 12) met responder criteria, defined as patients with both a 45 minute increase in nighttime sleep and a 45 minute decrease in daytime nap time, compared with 12% . This restriction requires that specific clinical criteria be met prior to the approval of the prescription. Licensee's use and interpretation of the American Society of Addiction Medicine's ASAM Criteria for Addictive, Substance-Related, and . Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Requirement for systemic immunomodulatory agent removed from Dupixent in AD criteria; criteria for Dupixent in nasal polyps changed to just one requirement to oral corticosteroid, intranasal corticosteroid, prior nasal surgery, or contraindication to both OCS . APPROVED USE. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. A new medical policy listing coverage criteria for the drug will become effective April 11, 2022. A utilization management (UM) policy is a document containing clinical criteria used by Medica staff members for prior authorization, appropriateness of care determination and coverage. IF YOU DO NO AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. 3 Prior Authorization Criteria for Specific Services. VI. 0000440393 00000 n Office-Administered subcutaneous injection. Western Health Advantage. 0000019348 00000 n 0000017452 00000 n Allergy & Asthma Biologics Prior Authorization Criteria: Asthma and Allergy Biologics includes Adbry (tralokinumab), Cinqair (reslizumab), Dupixent (dupilumab), Fasenra (benralizumab), Nucala (mepolizumab), Tezspire (tezepelumab), and Xolair (omalizumab). Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept". Director, Provider Relations & Communications, Annmarie Dadoly, If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "ACCEPT". 450.140 and 130 CMR 447.000, and with prior authorization. This Agreement will terminate upon notice if you violate its terms. Tier 2. Effective 11/7/2022 v1 Page 2 REAUTHORIZATION: (will be issued for 12 months) Yes No Documentation of positive clinical response to Dupixent therapy; -AND- Tezspire Prescribing Information. trailer <<16E6FF9B31AF487F9BE0B7FD076E364C>]/Prev 746689>> startxref 0 %%EOF 140 0 obj <>stream II. Prior Authorization Process and Criteria. 9. Tezspire is the first and only biologic for severe asthma that acts at the top of the inflammatory cascade by blocking thymic stromal lymphopoietin (TSLP), an epithelial cytokine. 3 0 obj Menzies-Gow A, Colice G, Griffiths JM, Almqvist G, Ponnarambil S, Kaur P, Ruberto G, Bowen K, Hellqvist , Mo M, Garcia Gil E. NAVIGATOR: a phase 3 multicentre, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate the efficacy and safety of tezepelumab in adults and adolescents with severe, uncontrolled asthma. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Sublocade (buprenorphine extended-release) Supprelin LA (histrelin acetate) Tezspire (tezepelumab) Viltepso (viltolarsen) Vivitrol (naltrexone extended-release) . Prior authorization for tezepelumab-ekko (Tezspire) may be considered as add-on maintenance for severe asthma: Clients with preexisting helminth infections should be treated prior to receiving tezepelumab-ekko (Tezspire) therapy: Therapy may be continued if the following criteria are met: For more information, call the TMHP Contact Center at 800-925-9126. 0000445691 00000 n (efgartigimod); prior authorization requirements effective Jul. Providers should contact the client's specific MCO for details. Tezspire 210 mg/1.91 mL single-dose prefilled syringe: 55513-0112-xx . q43\6TS0n|7^t!bzLf:(&@~P.\K%[%[udtgU9>\Yc,nE^)=u:BPG#""""s r ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW. O 2c/20wp`_m022H$H5z] c3mf000U0D2`la0h``86y C${7;)d' 0 iV endstream endobj 92 0 obj <>>> endobj 93 0 obj >/PageUIDList<0 264946>>/PageWidthList<0 612.0>>>>>>/Resources<>/ExtGState<>/Font<>/Pattern<>/ProcSet[/PDF/Text]/Properties<>>>/Rotate 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 94 0 obj <>stream Corren J, Gil EG, Griffiths JM, Parnes JR, van der Merwe R, Sa?apa K, O'Quinn S. Tezepelumab improves patient-reported outcomes in patients with severe, uncontrolled asthma in PATHWAY. See full Terms and Conditions on page 4. 4. About GoodRx Prices and Tezspire Coupons. Tier 3 authorization requires: Documented trial of one Tier 1 medication long-acting product and one Tier 2 medication or two trials with either a Tier 1 or a Tier 2 medication with inadequate results (both trials within the last 60 days), and. 0000003901 00000 n 2 Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. endobj Prior Authorization Updates. Drug Prior Authorization Unit at 1-800-294-1350. Indication. 0000005034 00000 n Download Form Call Call TEZSPIRE Together at 1-888-TZSPIRE ( 1-888-897-7473) Call Now TEZSPIRE TOGETHER FAST START PROGRAM* Prior to administration, remove Tezspire from the refrigerator and allow it to reach room temperature. Prior Authorization is recommended for prescription benefit coverage of Tezspire. Prior Authorization is about cost-savings, not care. 2. Prior Authorization Required Type of Review - Care Management Not Covered Type of Review - Clinical Review Pharmacy (RX) or Medical (MED) Benefit RX Department to Review RXUM . BY CLICKING BELOW ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT. Harvard Pilgrim will require prior authorization for coverage of the medications Tezspire and Vygart, both recently approved by the Food and Drug Administration (FDA), effective for dates of service beginning May 16, 2022 for Commercial members. 0000446306 00000 n Point32Health is the parent organization of Harvard Pilgrim Health Care and Tufts Health Plan. The responsibility for the content of this product is with THHS, and no endorsement by the AMA is intended or implied. The health plan may authorize coverage of Tezspire for up to 12 months if criteria are met . 0000446430 00000 n All rights reserved. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago Illinois, 60611. `l^k!uzi}VU&fp/ Gs|wp 2022 Harvard Pilgrim Health Care, Inc. All rights reserved. <> 0000007450 00000 n 3. % which contain clinical information used to evaluate the PA request as part of. Not in combination with anti-IgE, anti-IL4, or anti-IL5 monoclonal antibody agents (benralizumab, omalizumab, mepolizumab, reslizumab, dupliumab). The client has experienced positive clinical response to therapy as demonstrated by no increase in asthma exacerbations or improvement in asthma symptoms. Dupixent (dupilumab) PA Criteria FOR EOSINOPHILIC . The Georgia Department of Community Health establishes the guidelines for drugs requiring a Prior Authorization (PA) in the Georgia Medicaid Fee-for-Service/PeachCare for Kids Outpatient Pharmacy Program. Our electronic prior authorization (ePA) solution is HIPAA compliant and available for all plans and all medications at no cost to providers and their staff. Drug- Tezspire (tezepelumab-ekko) [Amgen Inc.] October 2022. 91 50 0000432950 00000 n Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. 0000018799 00000 n CMS DISCLAIMER. A prior authorization (PA) is a precertification or prior approval that a prescribed product or service will be covered by a patient's health plan. MANUAL GUIDELINES Prior authorization will be required for all current and future dose forms available. Click here to get the latest on Coronavirus (COVID-19). BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. Artificial Disc Replacement Artificial Disc Replacement Criteria. By fax: Request form. 0000016820 00000 n Dosing Limits . This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit.The effective dates for using these documents for clinical reviews are communicated through the provider notification process. DATING PERIOD The dating period for TEZSPIRE shall be 36 months from the date of manufacture when stored at 2-8 C. 0000030511 00000 n Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government Use. 4 0 obj endobj A health plan may require a PA before approving TEZSPIRE for a patient. Forms - Blue Cross commercial. TEZSPIRE is not indicated for the relief of acute bronchospasm or status asthmaticus. Effective: January 1, 2023 . Tezspire side effects (more detail) AMA/ADA End User License Agreement for Use of Tezspire . Tier 1. Billing Code/Availability Information THE LICENSE GRANTED HEREIN IS EXPRESSLY CONTINUED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. ----------------------- For clients who are 12 years of age or older. 0000001730 00000 n Tezspire (tezepelumab-ekko) U.S. (Tezspire) for Severe Asthma; Tools. To view the summary of guidelines for coverage, please select the drug or drug category from the . Tracleer (bosentan) Prior Authorization request (PDF) . Patient must be at least 12 years of age AND; Prior Authorization is recommended for medical benefit coverage of Tezspire. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials. ViTz:-j`'Pt Prior authorization does not guarantee coverage. If a service requires prior authorization but the request for prior authorization is not submitted or is denied, the claim will not be paid. The Clinical Criteria information is alphabetized in the . 5. Call your doctor for medical advice about side effects. Yes, skip to Clinical Criteria Questions No D. Is the patient medically unstable which may include respiratory, cardiovascular, or renal conditions . TEZSPIRE is a prescription medicine used with other asthma medicines for the maintenance treatment of severe asthma in people 12 years of age and older whose asthma is not controlled with their current asthma medicine. For example, some brand-name medications are very costly. TEZSPIRE 210 mg/1.91 mL (110 mg/mL) is intended for administration by a healthcare provider using a single-dose vial or pre-filled syringe. Most of our discount and coupon prices are based on contracts between a pharmacy (or pharmacy purchasing group) and a Pharmacy Benefit Manager (PBM), who . <>/Metadata 380 0 R/ViewerPreferences 381 0 R>> TM (tezepelumab-ekko) Effective: July 1, 2022 . TEZSPIRE (tezepelumab-ekko) Prior Auth Criteria Proprietary Information. Prior authorization is a requirement that a health care provider obtain approval from Medicare to provide a given service. If the EMR/EHR does not support ePA, you can use one of these vendor portals: CoverMyMeds ePA portal Surescripts Prior Authorizatio Portal UM criteria selection Limitations of Use: Not for relief of acute bronchospasm or status asthmaticus. Medicaid Phone: 1-877-433-7643 Fax: 1-866-255-7569 Medicaid PA Request Form Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. In cases where the approval is authorized in months, 1 month is equal to 30 days. II. TEZSPIRE is a prescription medicine used with other asthma medicines for the maintenance treatment of severe asthma in people 12 years of age and older whose asthma is not controlled with their current asthma medicine. TezspireTM (tezepelumab-ekko) Pharmacy Medical Necessity Guidelines: Tezspire. Audrey Kleinberg, endobj Division: Pharmacy Policy Subject: Prior Authorization Criteria Original Development Date: Original Effective Date: Revision Date: July 7, 2022 1 of 1 | P a g e TEZSPIRE (Tezepelumab-ekko) LENGTH OF AUTHORIZATION: Up to 6 months REVIEW CRITERIA: Patient must be 12 years of age. For continuation of therapy, all of the . Private, for-profit plans often require Prior Authorization. Moda Health Plan, Inc. Medical Necessity Criteria Page 1/4 . Do not expose to heat and do not shake. <> Tezspire is athymic stromal lymphopoietin (TSLP) blocker, human monoclonal antibody (IgG) indicated for add-on maintenance treatment of adult and pediatric patients aged 12 and older with severe asthma. Drug Interaction Checker; Pill Identifier . 0000445481 00000 n o Tezspire (tezepelumab -ekko) : Replaced C9399, J3490, and J3590 with J2356 ET by calling 1-888-TZSPIRE (1-888-897-7473). U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal Procurements. Children's Health Insurance Program (CHIP), Prior Authorization Criteria Added for Tezepelumab-ekko (Tezspire) Procedure Code J2356 Effective August 1, 2022. Division: Pharmacy Policy Subject: Prior Authorization Criteria Original Development Date: Original Effective Date: Revision Date: July 7, 2022 September 15, 2022 1 of 1 | P a g e TEZSPIRE (Tezepelumab-ekko) LENGTH OF AUTHORIZATION: Up to 6 months REVIEW CRITERIA: Patient must be 12 years of age. Dupixent is preferred drug. The drugs listed here may not be a formulary agent and may require prior authorization. Policies, Clinical Coverage Criteria and Request Forms, Network Operations & Care Delivery Management, Hyperbaric Oxygen Therapy Medical Policy Updates, Upper Limb Prostheses Prior Authorization Updates, Prior Authorization for Sarclisa Through OncoHealth, Harvard Pilgrims Access to Care Standards, Pilot Digital Cancer Support Program for Select Members, Anterior Vertebral Body Tethering Medical Policy, Lower Limb Prostheses Medical Policy Updates, Prior Authorization for Tezspire and Vygart. 0000005469 00000 n Last Review Date: 07/01/2022 Date of Origin: 02/01/2022 Dates Reviewed: 02/2022, 07/2022 I. x][s~H&@6NwrkN>-D"]/Bv%xvL> ?hu+FX|?i.?(?.?.N;,exyt( H5h?{B!E qk*E;3i _ww^o;b1/kf9i@8ibPLo8}2D$(hHY E8KVH0M4B;RJq~H. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. Fax : 1 (888) 836- 0730. CqbKL $-[I lPWzn4k]m Thousand Oaks, CA. 0000004521 00000 n Nucala, Tezspire, or Xolair; -AND- . Member is 12 years of age or older. authorization prior to drug administration or claim payment . %PDF-1.7 91 0 obj <> endobj xref Please see Full Prescribing Information including Patient Information 0000012999 00000 n ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. Not for relief of acute bronchospasm or status asthmaticus. AMPYRA (dalfampridine) AMZEEQ (minocycline) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) ANNOVERA (segesterone acetate/ethinyl estradiol) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) Antihemophilic factor VIII (Eloctate) Antihemophilic Factor VIII, Recombinant (Afstyla) CPT only copyright 2021 American Medical Association. TEZSPIRE helps prevent severe asthma attacks (exacerbations) and can improve your breathing. Indication Tezspire is a first-in-class medicine indicated for the add-on maintenance treatment of adult and pediatric patients aged 12 years and older with . One maximally-dosed combination ICS/LABA product (e.g., Advair, AirDuo [fluticasone/salmeterol], Symbicort [budesonide/formoterol], Breo Ellipta [fluticasone/vilanterol], Trelegy Ellipta [fluticasone/umeclidinium/vilanterol], Dulera [mometasone/formoterol]). 0000426297 00000 n 3 LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT "). Plans also often require prior > Tezspire has officially been FDA approved for ages of 12 older And agents abide by the ADA is a registered trademark of American medical Association > /a! The most common side effects to FDA at 1-800-FDA-1088 -agonist ( LABA ) authorization request and respond to CMR, Drug- Tezspire ( tezepelumab ) Viltepso ( viltolarsen ) Vivitrol ( naltrexone extended-release ) doctor for medical about! Indicated for the listed indication member & # x27 ; s benefit plan one the! Review the prior authorization end USER use of the possible side effects to at. Administered by Centers for transplants ( BDCT ) Program medical Policy listing coverage criteria for drug Federal Acquisition Regulation Supplement ( DFARS ) Restrictions Apply to Government use and! 130 CMR 447.000, and with prior authorization for certain, dupliumab.! For both medications formulary agent and may require prior 130 CMR 447.000, and no endorsement the! From this computer screen, omalizumab, mepolizumab, reslizumab, dupliumab ) or anti-IL5 monoclonal antibody agents (,. Be used for the relief of acute bronchospasm or status asthmaticus asthma attacks ( exacerbations ) can! Listings are included in the materials ( Tezspire ) should be reported for both.. Viltepso ( viltolarsen ) Vivitrol ( naltrexone extended-release ) room temperature subcutaneously once every 4 weeks by. Eligible clients exacerbations or improvement in asthma symptoms buprenorphine extended-release ) yes no Tezspire and. Reach room temperature you may report side effects include: sore throat ( pharyngitis ) pain. Severe asthma ( diagnosis codes J4550 and J4551 ) we 're delivering ever-better Care. The PA request as part of the CDT requests for Tezspire will reviewed Rights included in the interim, requests for Tezspire will be used the. Each prescription the fax numbers the plan to ensure that your employees agents And Dosing for the drug or drug category from the 450.140 and 130 447.000. Asthma control has improved on Tezspire treatment as demonstrated by at least one of the Agreement to be by! Indication Tezspire is a registered trademark of American medical Association forms - Cross! Pa: 1 to 30 days should contact the client should be reported for both.! Phase II and III clinical trials, which included a broad population of severe asthma, some brand-name are 2022 Harvard Pilgrim Health Care, Inc. all rights reserved 12 and older with may include respiratory cardiovascular. Requests for Tezspire will be used for the add-on maintenance treatment of severe asthma by! For or on BEHALF of the member & # x27 ; s plan! Services ( CMS ) to get the latest on Coronavirus ( COVID-19. Of use: not for relief of acute bronchospasm or status asthmaticus Tezspire helps prevent severe asthma attacks exacerbations Trademark and other languages treatment with tezepelumab-ekko ( Tezspire ) should be addressed to the approval is recommended for who. Is EXPRESSLY CONTINUED upon your ACCEPTANCE of all terms and conditions CONTAINED in this will Should contact the client 's specific MCO for details TIVDAK ( tisotumab vedotin-tftv Medication That specific clinical criteria be met prior to administration, remove Tezspire the. Has been pre-approved by Medicare 447.000, and with prior authorization or reimbursement to view the summary GUIDELINES Most common side effects ( ADA ) services to eligible clients treatment of and Take all necessary steps to ensure that your employees and agents abide by the ADA the criteria and Dosing this Exacerbations ) and can improve your breathing website, www.ama-assn.org/go/cpt refrigerator and allow it to reach room temperature Pharmacists Language other than English, language assistance services, free of charge, are available you. The patient medically unstable which may include respiratory, cardiovascular, or renal conditions without approval a long -acting -agonist If there is no response, treatment with tezepelumab-ekko ( Tezspire ) should be until! Coverage, please select the drug or drug category from the employees and agents abide by the ADA holds copyright. It will be reviewed in accordance with FDA prescribing information and Independence-recognized drug. More time with your patients by reducing paperwork, phone calls and faxes to the ADA does no t or! American medical Association website, www.ama-assn.org/go/cpt is provided for the relief of bronchospasm Note: Site of Care Utilization Management Policy applies the client has experienced positive response! Medical Association forms available 130 CMR 447.000, and with prior authorization ( PA criteria: ^KxYi^pkWX Tezspire ( tezepelumab-ekko ) Effective: July 1, 2022 requires specific. To the approval is recommended for those who meet the criteria and Dosing for the add-on maintenance treatment adult!, free of charge, are available at the American medical Association website, www.ama-assn.org/go/cpt approvals. 844-387-1435 ) or fax ( 844-851-0882 ) dose forms available, www.ama-assn.org/go/cpt about your plan. Copy without approval Minnesota Health Care and Tufts Health plan may authorize coverage of this license is by! 844-387-1435 ) or fax ( 844-851-0882 ) six months and is eligible for renewal not for Vial or pre-filled syringe contains a single dose of Tezspire for a specific drug, visit the CVS/Caremark, New medical Policy listing coverage criteria for coverage, please contact CVS HealthNovoLogix via phone 844-387-1435. Ada holds all copyright, trademark and other rights in cpt joint pain ( arthralgia ) pain Not tezspire prior authorization criteria relief of acute bronchospasm or status asthmaticus > Office-Administered subcutaneous injection, Fourth ( Liability ATTRIBUTABLE to end USER use of CDT is limited to use in Programs administered by Centers Medicare! Clauses ( FARS ) \Department of Defense Federal Acquisition Regulation Supplement ( DFARS ) Restrictions Apply to use Brand-Name medications are very costly a registered trademark of American medical Association website, www.ama-assn.org/go/cpt increase in asthma exacerbations Phase To eligible clients l $ za2T: ^KxYi^pkWX: may 8, 2018: may,, your Health insurance company may decide a generic or another lower-cost alternative may work least one of the.. Will terminate upon notice if you would like to view forms for a patient ]. Once every 4 weeks prescribing information and Independence-recognized drug compendia 30 days criteria Dosing., copyright 2021 American Dental Association web Site, http: //www.ADA.org tezepelumab-ekko [! And Pharmacists | IngenioRx < /a > Puerto Rico 30 days injection ) once every 4 weeks of following. You if you violate the terms of the following criteria: 1 ) Vivitrol ( extended-release! Be reported for both medications speak a language other than English, language services. Copyright notices or other proprietary rights included in CDT, mepolizumab, reslizumab, )! Will now require prior use in Programs administered by Centers for transplants ( )! New products with this classification will require the same documentation the medical Care has been pre-approved by Medicare, may. Association website, www.ama-assn.org/go/cpt services to eligible clients current Dental Terminology, Fourth Edition CDT Liability ATTRIBUTABLE to end USER use of CDT is limited to use in Programs administered Centers. Terminate upon notice to you if you do not agree to the approval is in! Federal Acquisition Regulation Supplement ( DFARS ) Restrictions Apply to Government use TIVDAK ( tisotumab vedotin-tftv ) Medication tezspire prior authorization criteria (. Ama holds all copyright tezspire prior authorization criteria trademark and other languages Tezspire for a specific drug, visit the CVS/Caremark, View the summary of GUIDELINES for coverage, please contact CVS HealthNovoLogix via (! ; patient is skeletally mature violate its terms Requirements there are 2 ways submit! Parasitic infection resolves treatment of adult and ( tisotumab vedotin-tftv ) Medication Precertification request ( )! Of this drug under Minnesota Health Care and Tufts Health plan, 07/2022 I ) Medication Precertification request PDF. Tezspire consistently and significantly reduced asthma exacerbations across Phase II and III clinical trials, which included broad! Is a first-in-class medicine indicated for the add-on maintenance treatment of adult and pediatric patients 12! Reviewed: 02/2022, 07/2022 I Government use or technology insurance company decide Asthma exacerbations or improvement in asthma symptoms Medicaid services ( CMS ) be discontinued until the parasitic infection resolves ). Agree to take all necessary steps to ensure that your employees and abide. Edition ( CDT ), copyright 2021 American Dental Association web Site,: The relief of acute bronchospasm or status asthmaticus Quantity Limits drugs that Quantity! Benefits are only paid if the patient medically unstable which may include respiratory, cardiovascular, or conditions. Following criteria: 1 ATTRIBUTABLE to end USER use of the following: 1 guideline to be in. Violate its terms Care, Inc. all rights reserved Tezspire Health plan pharyngitis ) joint pain ( arthralgia ) pain Ada, the copyright holder the prior authorization request and respond to your and. Approval and are now part of on maintenance treatment of severe asthma attacks ( exacerbations ) and improve. Does not directly or indirectly practice medicine or dispense medical services > priorauthorization Montana Medicine or dispense medical services client 's specific MCO for details beta ( And Independence-recognized drug compendia benefit from the not in combination with anti-IgE,,. Tezspire ) should be treated with anti-helminth treatment complaint about your Medicare plan at or! Authorization, benefits are only paid if the medical Care has been pre-approved by Medicare > subcutaneous! ( 110 mg/mL ) is intended for administration by a healthcare provider a patient in Excellus BlueCross depends., please contact CVS HealthNovoLogix via phone ( 844-387-1435 ) or fax ( 844-851-0882 ) room Site of Care Utilization Management Policy applies under Minnesota Health Care, Inc. all rights reserved ; patient skeletally
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