Complete Guide to Getting Tepezza (Teprotumumab) Covered by Blue Cross Blue Shield in Pennsylvania: Prior Authorization, Appeals, and Success Strategies
Answer Box: Quick Path to Tepezza Coverage
To get Tepezza (teprotumumab) covered by Blue Cross Blue Shield in Pennsylvania, you need prior authorization showing moderate-to-severe thyroid eye disease (Clinical Activity Score ≥3), euthyroid status, and either failed corticosteroid treatment or documented contraindication. Submit through your provider portal or fax to the plan-specific number with complete clinical documentation. If denied, Pennsylvania's new external review program overturns approximately 50% of appeals. Start by gathering thyroid labs, CAS documentation, and prior treatment records today.
Table of Contents
- Who Should Use This Guide
- Member & Plan Basics
- Clinical Criteria Requirements
- Coding and Billing Requirements
- Documentation Packet Checklist
- Submission Process
- Specialty Pharmacy Network
- After Submission: Tracking Your Request
- Common Denial Reasons & Solutions
- Appeals Process in Pennsylvania
- Cost Support Programs
- Frequently Asked Questions
Who Should Use This Guide
This guide helps Pennsylvania residents with Blue Cross Blue Shield coverage navigate the prior authorization process for Tepezza (teprotumumab), a specialty medication for thyroid eye disease (TED). You'll need this if:
- Your ophthalmologist or endocrinologist has recommended Tepezza for moderate-to-severe TED
- You've received a denial for Tepezza coverage
- Your pharmacy or infusion center needs prior authorization before treatment
- You're preparing to appeal a Blue Cross denial
Expected Outcome: With proper documentation, most patients meeting clinical criteria can obtain coverage. Pennsylvania's strengthened appeals process has achieved a 50% overturn rate for wrongful denials.
Member & Plan Basics
Coverage Requirements
Your Blue Cross Blue Shield Pennsylvania plan must be active with medical benefits. Tepezza is covered under the medical benefit (not pharmacy) using HCPCS code J3241.
Note: Self-funded employer plans may have different requirements and aren't eligible for Pennsylvania's external review process.
Plan Types Covered
- Commercial Blue Cross plans (Highmark, Independence Blue Cross)
- ACA marketplace plans through Pennie
- Medicare Advantage Blue Cross plans
- Some Medicaid managed care plans
Authorization Requirements
All Blue Cross Blue Shield plans in Pennsylvania require prior authorization for Tepezza. There are no deductible exemptions for this specialty medication.
Clinical Criteria Requirements
Core Eligibility Criteria
| Requirement | Details | Documentation Needed |
|---|---|---|
| Age | 18 years or older | Date of birth verification |
| Diagnosis | Moderate-to-severe thyroid eye disease | Clinical Activity Score ≥3 |
| Thyroid Status | Euthyroid or within 50% of normal range | Recent TSH, free T3, free T4 (within 30 days) |
| Prior Treatment | Failed corticosteroids OR contraindication | Treatment records or medical contraindication notes |
| Prescriber | Board-certified ophthalmologist or endocrinologist | Provider credentials verification |
Clinical Activity Score Documentation
Your physician must document a Clinical Activity Score (CAS) ≥3 based on these inflammatory signs:
- Spontaneous orbital pain
- Gaze-evoked orbital pain
- Eyelid swelling and erythema
- Conjunctival redness and chemosis
- Inflammation of caruncle or plica
- Increase in proptosis (≥2 mm)
- Decreased eye movements (>8° in any direction)
- Decrease in visual acuity (≥1 Snellen line)
Treatment Limits
- Maximum 8 intravenous infusions over 6 months
- Weight-based dosing (10 mg/kg first dose, then 20 mg/kg × 7 doses)
- Only one prior authorization approval per member's lifetime
Coding and Billing Requirements
HCPCS Coding
- Primary Code: J3241 (teprotumumab-trbw, 10 mg per unit)
- Units: Based on weight and dosing schedule
- First infusion: ~150 units (1,500 mg)
- Subsequent infusions: ~250 units (2,500 mg)
Required Modifiers
- JW modifier: When drug amount was discarded
- JZ modifier: When zero drug amount was discarded
ICD-10 Diagnosis Codes
- E05.00: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis
- H05.20: Unspecified exophthalmos
- H05.21: Displacement of globe
- H05.22: Edema of orbit
Documentation Packet Checklist
Provider Clinical Notes Must Include:
✓ Formal TED diagnosis with onset date
✓ Clinical Activity Score calculation and documentation
✓ Proptosis measurements in millimeters
✓ Visual acuity assessments
✓ Prior corticosteroid treatment details (dates, doses, response) OR contraindication explanation
✓ Current thyroid function status
✓ Treatment goals and monitoring plan
Required Laboratory Results:
✓ TSH, free T3, free T4 (within 30 days)
✓ Baseline glucose levels
✓ Pregnancy test (if applicable)
Letter of Medical Necessity Components:
✓ Patient demographics and insurance information
✓ Detailed TED diagnosis and severity assessment
✓ Clinical rationale for Tepezza specifically
✓ Previous treatment failures or contraindications
✓ Expected treatment outcomes
✓ Provider signature and credentials
Supporting Attachments:
✓ Clinical photographs showing disease severity
✓ Specialist consultation notes
✓ Relevant imaging results
✓ Previous treatment records
Submission Process
Fastest Submission Methods
Electronic Submission (Recommended):
- UnitedHealthcare Provider Portal (for OptumRx-administered plans)
- CoverMyMeds integration
- Plan-specific provider portals
Fax Submission:
- OptumRx: 1-844-403-1027
- Plan-specific fax numbers (verify current numbers)
Processing Timelines
- Standard Review: Up to 15 business days
- Urgent Cases: 72 hours
- Electronic submissions typically process faster than fax
Required Form Fields
Ensure all fields are complete to avoid automatic rejections:
- Patient name and date of birth (exactly as on insurance card)
- Policy/member ID number
- Provider NPI and contact information
- Requested medication name and strength
- ICD-10 diagnosis codes
- Prescriber signature and date
Specialty Pharmacy Network
In-Network Specialty Pharmacies
Accredo Health Group: 1-888-608-9010
CVS/Caremark: 1-800-237-2767
Important: Use only in-network specialty pharmacies to receive full benefits coverage.
Buy-and-Bill Option
Accredo Ophthalmic TRC ships directly to infusion centers for immediate administration. This eliminates patient pickup requirements and ensures proper cold-chain handling.
After Submission: Tracking Your Request
Confirmation Steps
- Record confirmation numbers from electronic submissions
- Save fax confirmation receipts for paper submissions
- Follow up within 3-5 business days if no acknowledgment received
Status Check Schedule
- Week 1: Confirm receipt and completeness review
- Week 2: Check for any additional information requests
- Day 15: Contact if no decision received for standard reviews
What to Document
- Submission date and method
- Confirmation numbers
- Names of representatives spoken with
- Any additional information requests
- Decision dates and reference numbers
Common Denial Reasons & Solutions
| Denial Reason | Solution Strategy | Required Documentation |
|---|---|---|
| Insufficient CAS documentation | Resubmit with detailed CAS calculation | Clinical examination notes with specific inflammatory signs |
| No prior steroid trial | Document previous corticosteroid treatment OR medical contraindication | Treatment records or contraindication explanation with medical rationale |
| Incomplete thyroid labs | Submit recent lab results | TSH, free T3, free T4 within 30 days |
| Coding errors | Verify correct HCPCS code and units | J3241 with proper unit calculations |
| Missing clinical photos | Include baseline disease documentation | Clinical photographs showing proptosis and inflammation |
Appeals Process in Pennsylvania
Pennsylvania offers one of the strongest patient appeal systems in the country. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and drafting point-by-point rebuttals aligned to the plan's own rules.
Internal Appeals (First Level)
- Deadline: 180 days from denial date
- Timeline: 15 business days for standard review, 72 hours for urgent
- Submission: Through plan's member portal or appeals department
Pennsylvania External Review (Second Level)
- Deadline: 4 months after final internal denial
- Success Rate: Approximately 50% of appeals overturned
- Timeline: 45 days for standard review, 72 hours for expedited
- Submission: reviewmyclaim.pa.gov or 1-877-881-6388
Required Appeal Documentation
✓ Copy of denial letter
✓ Medical records supporting medical necessity
✓ Additional clinical evidence (studies, guidelines)
✓ Provider statement of medical necessity
✓ Insurance card copy
From our advocates: "We've seen significant success when appeals include specific citations from FDA labeling and thyroid eye disease treatment guidelines. The key is addressing each denial reason with corresponding clinical evidence and showing how the patient meets the plan's own published criteria."
Cost Support Programs
Amgen By Your Side Program
Provides coverage investigation, prior authorization support, and financial assistance for eligible patients.
- Phone: Contact through prescriber
- Services: Insurance navigation, copay assistance, free drug programs
Financial Assistance Options
- Copay cards: May reduce out-of-pocket costs for commercially insured patients
- Patient assistance programs: For uninsured or underinsured patients
- Foundation grants: Through organizations like the Patient Advocate Foundation
Frequently Asked Questions
How long does Blue Cross Blue Shield PA take in Pennsylvania?
Standard prior authorization reviews take up to 15 business days. Urgent cases are decided within 72 hours. Electronic submissions through provider portals typically process faster than fax submissions.
What if Tepezza is non-formulary on my plan?
You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate. Include documentation of contraindications or failures with covered alternatives.
Can I request an expedited appeal if my condition is worsening?
Yes. Pennsylvania allows expedited external reviews for urgent health situations. Include physician certification that delayed treatment poses a serious threat to your health.
Does step therapy apply if I failed steroids in another state?
Treatment failures from other states should be accepted if properly documented. Include complete medical records showing the treatment trial, duration, and reason for discontinuation.
What happens if my appeal is successful?
The insurer must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal process.
Who can help me with the appeals process?
Pennsylvania offers free assistance through the Pennsylvania Health Law Project and other consumer assistance programs. Counterforce Health also provides specialized support for complex medication appeals.
Sources & Further Reading
- Pennsylvania Insurance Department External Review Program
- Tepezza Prescribing Information (FDA)
- Amgen By Your Side Support Program
- Pennsylvania External Review Portal
- Tepezza Healthcare Provider Resources
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For additional assistance with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department at 1-877-881-6388.
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