TEZSPIRE BILLING AND CODING GUIDE

1 National Drug Code (NDC)1 Administration MethodDosageCodePhysician Administered: Prefilled SyringeCarton contains one 210 mL (110 mg/mL) prefilled syringe10-digit NDC55513-112-0111-digit NDC55513-0112-01 Although the FDA uses a 10-digit format when registering NDC numbers, payers often require an 11-digit NDC format on claim forms for BILLING purposes. It is important to confirm with your payer which NDC format is required. In addition, Medicaid requires that all claims for provider-administered drugs include NDC reporting requirement may also be implemented by some commercial payers. Guidelines for reporting the NDC number in the appropriate format, quantity, and unit of measure vary by state and by payer and should be reviewed prior to submitting a Common Procedure CODING System (HCPCS)2 CodeDescriptionJ2356 Injection, tezepelumab-ekko, 1 mg For dates of service on or after July 1, 2022, healthcare providers administering TEZSPIRE can begin using the new Healthcare Common Procedure CODING System (HCPCS) code assigned by the Centers for Medicare & Medicaid Services (CMS) and discontinue use of the temporary codes J3590, J3490, and C9399 Current Procedural Terminology (CPT) 3 DescriptionInjection AdministrationHealthcare providers should consult the payer or Medicare contractor to determine the code most appropriate to report for administration.

2 It is the provider s responsibility to ensure that codes used are consistent with payer policy and reflect the service Codes4 ICD-10-CM persistent asthma, persistent asthma with (acute) exacerbationThe information provided in this GUIDE is of a general nature, for informational purposes only and is not intended to be a comprehensive list nor instructive. CODING and coverage policies change periodically and often without warning. The responsibility to determine coverage and reimbursement parameters, and appropriate CODING for a particular patient and/or procedure, is always the responsibility of the provider or physician. The information provided in this GUIDE should in no way be considered a guarantee of coverage or reimbursement for any product or is indicated for the add-on maintenance treatment of adult and pediatric patients aged 12 years and older with severe asthma.

3 TEZSPIRE is not indicated for the relief of acute bronchospasm or status hypersensitivity to tezepelumab-ekko or see additional important safety information on page BILLING AND CODING GUIDE1 APPROVED OMB-0938-1197 FORM 1500 (02-12) PLEASE PRINT OR TYPEC ompleting the CMS 1500 for Physician OfficesSample CMS 1500 Form - Physician Office Administration1 2 4 TYPE OF BILL FROM THROUGH 5 FED. TAX NO. a b c d DX ECI A B C D E F G H I J K L M N O P Q a b c a b c a b c d ADMISSION CONDITION CODES DATE OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPAN CODE DATE CODE CODE CODE DATE CODE THROUGH VALUE CODES VALUE CODES VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT TOTALS PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE FIRST c. d. e. OTHER PROCEDURE NPICODE DATE DATE FIRST NPI b LAST FIRST c NPI d LAST FIRST 7 10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC DATE 16 DHR 18 19 20 FROM 21 2522 26 2823 27 CODE FROM DATE OTHER PRV ID b.

4 INFO BEN. CODE OTHER PROCEDURE THROUGH 29 ACDT 30 3231 33 34 35 36 37 38 39 40 41 42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 52 REL 51 HEALTH PLAN ID 53 ASG. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI 57 58 INSURED S NAME 59 60 INSURED S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME 66 67 68 69 ADMIT 70 PATIENT 72 73 74 75 76 ATTENDING 80 REMARKS OTHER PROCEDURE a 77 OPERATING 78 OTHER 79 OTHER 81CC CREATION DATE 3a PAT. CNTL # 24 b. MED. REC. # 44 HCPCS / RATE / HIPPS CODE PAGE OF e a8 PATIENT NAME 50 PAYER NAME 63 TREATMENT AUTHORIZATION CODES 6 STATEMENT COVERS PERIOD 9 PATIENT ADDRESS 17 STAT STATE DX REASON DX 71 PPS CODE QUAL LAST LAST OCCURRENCE QUAL QUAL QUAL CODE DATE a b 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C A B C a b 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 A B C A B C A B C UB-04 CMS-1450 APPROVED OMB NO.

5 0938-0997 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. National Uniform NUBC BILLING Committee LIC9213257 Completing the CMS 1450 for Outpatient Hospital-Based FacilitiesSample UB-04 (CMS 1450) Form - Hospital Outpatient AdministrationThis sample form is intended as a reference for CODING and BILLING for product and associated services. It is not intended to be directive, nor does the use of recommended codes guarantee reimbursement. Healthcare providers may deem other codes or policies more appropriate and should select the CODING options that most accurately reflect their internal system guidelines, payer requirements, practice patterns, and the services rendered. Healthcare providers are responsible for ensuring the accuracy and validity of all BILLING and claims for appropriate sample form is intended as a reference for CODING and BILLING for product and associated services.

6 It is not intended to be directive, nor does the use of recommended codes guarantee reimbursement. Healthcare providers may deem other codes or policies more appropriate and should select the CODING options that most accurately reflect their internal system guidelines, payer requirements, practice patterns, and the services rendered. Healthcare providers are responsible for ensuring the accuracy and validity of all BILLING and claims for appropriate reimbursement. Box 21. Diagnosis or Nature of Illness or Injury:Indicate appropriate ICD-10 diagnosis code. ICD-10 code example: 24A. Dates of Service:Medicaid and commercial payers may require NDC reporting for TEZSPIREBox 24D. Product and Procedure Codes:ProductJ2356 Related Administration ProcedureHealthcare providers should consult the payer or Medicare contractor to determine which CPT code is most appropriate for administration of TEZSPIRE1 Box 19.

7 Additional Claim information :Provide the drug name and dosageBox 24G. Days or Units:Indicate 210 for use of one prefilled syringe of TEZSPIRER eport appropriate number of units for the applicable CPT codeBox 42. Revenue Codes:ProductMedicare: Use revenue code 0636, drugs requiring detailed codingOther payers: Use revenue code 0250, general pharmacy (or 0636, if required by a given payer)Related Administration ProcedureUse most appropriate revenue code or cost center where services were performed (eg, 0510, clinic)Box 67. Diagnosis Codes:Indicate appropriate ICD-10 diagnosis code. ICD-10 code example: 80. Remarks:Payers typically require providers to list product name, route of administration, total dosage, and NDCBox 43. Description:Indicate the drug name and dosage: TEZSPIRE 210 mgBox 46. Service Units:Report appropriate number of units for the applicable CPT code Box 47. Total Charges:Report appropriate charges for product used and related proceduresBox 44.

8 Product and Procedure Codes:ProductJ2356 Related Administration ProcedureHealthcare providers should consult the payer or Medicare contractor to determine which CPT code is most appropriate for administration of (tezepelumab-ekko) 210 mg2 Anytime Hospital 100 Main StreetAnytown, Anystate 12345 TEZSPIRE (tezepelumab-ekko)subcutaneous, 210 mgNDC: 55513-0112-0106360510 TEZSPIRE (tezepelumab-ekko) 210 mgClinicJ235696 XXXMMDDYY MMDDYYXXXXXXXXXX2101123 Main Street Anytown, Anystate hypersensitivity to tezepelumab-ekko or AND PRECAUTIONSH ypersensitivity ReactionsHypersensitivity reactions ( , rash and allergic conjunctivitis) can occur following administration of TEZSPIRE . These reactions can occur within hours of administration, but in some instances have a delayed onset ( , days). In the event of a hypersensitivity reaction, initiate appropriate treatment as clinically indicated and then consider the benefits and risks for the individual patient to determine whether to continue or discontinue treatment with Asthma Symptoms or Deteriorating DiseaseTEZSPIRE should not be used to treat acute asthma symptoms, acute exacerbations, acute bronchospasm, or status Reduction of Corticosteroid DosageDo not discontinue systemic or inhaled corticosteroids abruptly upon initiation of therapy with TEZSPIRE .

9 Reductions in corticosteroid dose, if appropriate, should be gradual and performed under the direct supervision of a physician. Reduction in corticosteroid dose may be associated with systemic withdrawal symptoms and/or unmask conditions previously suppressed by systemic corticosteroid (Helminth) InfectionIt is unknown if TEZSPIRE will influence a patient s response against helminth infections. Treat patients with pre-existing helminth infections before initiating therapy with TEZSPIRE . If patients become infected while receiving TEZSPIRE and do not respond to anti-helminth treatment, discontinue TEZSPIRE until infection Attenuated VaccinesThe concomitant use of TEZSPIRE and live attenuated vaccines has not been evaluated. The use of live attenuated vaccines should be avoided in patients receiving REACTIONS The most common adverse reactions (incidence 3%) are pharyngitis, arthralgia, and back IN SPECIFIC POPULATIONST here are no available data on TEZSPIRE use in pregnant women to evaluate for any drug-associated risk of major birth defects, miscarriage, or other adverse maternal or fetal outcomes.

10 Placental transfer of monoclonal antibodies such as Tezepelumab-ekko is greater during the third trimester of pregnancy; therefore, potential effects on a fetus are likely to be greater during the third trimester of see accompanying TEZSPIRE full Prescribing information , including Patient are encouraged to report negative side effects of AstraZeneca prescription drugs by calling 1-800-236-9933. If you prefer to report these to the FDA, call is a trademark of Amgen Inc. and AstraZeneca. 2022 AstraZeneca. All rights reserved. Used with permission. USA-157-80524 05/22 important safety INFORMATIONR eferences: 1. TEZSPIRE (tezepelumab-ekko) [prescribing information ]. Thousand Oaks, CA: Amgen Inc. 2. HCPCS codes. HCPCS J-Codes. Accessed January 26, 2022. 3. American Medical Association. Current Procedural Terminology (CPT) Professional Edition. 2019 Edition. AMA; 2018. 4. American Medical Association.