By Counterforce Health Team in Tepezza (teprotumumab) —

Do You Qualify for Tepezza Coverage by Humana in New York? Decision Tree & Appeals Guide

Answer Box: Your Fastest Path to Approval

If you have thyroid eye disease (TED) with Clinical Activity Score ≥4, documented proptosis, and are euthyroid, Humana likely covers Tepezza under Medicare Part B with prior authorization. Submit through your ophthalmologist with complete documentation including CAS assessment, thyroid labs, and prior steroid failure records. Standard approval takes 72 hours to 14 days. If denied, you have 65 days to appeal internally, then can file for New York's external review within 4 months—which overturns ~50-60% of denials.

Start today: Verify your Humana plan covers J3241 at provider.humana.com and schedule ophthalmology evaluation for CAS documentation.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Approval Checklist
  4. If "Possibly Eligible": Tests and Timeline
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: New York Appeals Path
  7. Coverage at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Costs and Financial Assistance
  10. FAQ: Your Top Questions Answered

How to Use This Decision Tree

This guide helps you determine if Humana will cover Tepezza (teprotumumab) for thyroid eye disease in New York, and what to do at each stage. Tepezza costs $350,000-$500,000+ for a full course, making prior authorization critical.

Before you start, gather:

  • Insurance card with member ID
  • Recent thyroid function tests (TSH, T4, T3)
  • Eye exam records showing proptosis measurements
  • Documentation of prior treatments tried
  • Photos showing eye changes over time
Tip: Counterforce Health specializes in turning insurance denials into evidence-backed appeals for complex specialty drugs like Tepezza. Their platform analyzes denial letters and creates targeted rebuttals using the payer's own criteria.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible if you have:

  • Confirmed TED diagnosis by ophthalmologist or endocrinologist
  • Clinical Activity Score (CAS) ≥4 on 7-point scale (or ≥3 with progression)
  • Documented proptosis via Hertel exophthalmometry
  • Euthyroid status (TSH, T4, T3 within 50% of normal range)
  • Prior steroid failure or contraindication documented
  • Age 18+ with active symptoms affecting quality of life

⚠️ Possibly Eligible if you have:

  • TED diagnosis but CAS 2-3 without clear progression
  • Mild hyperthyroidism (T4/T3 <50% outside normal but trending toward normal)
  • Recent steroid trial but unclear if adequate dose/duration
  • Stable disease but with significant functional impairment

❌ Not Yet Eligible if you have:

  • No specialist evaluation for TED
  • CAS <2 or inactive disease
  • Uncontrolled thyroid levels (T4/T3 >50% outside normal range)
  • No documented prior therapy attempts
  • Pregnancy or planning pregnancy

If "Likely Eligible": Your Approval Checklist

Step 1: Verify Network Coverage (1-2 days)

  • Call Humana at 1-833-704-1024 with member ID
  • Confirm ophthalmologist is in-network
  • Verify J3241 (Tepezza) requires prior authorization
  • Ask about infusion site requirements

Step 2: Gather Required Documentation

Medical necessity letter must include:

  • Patient demographics and Humana member ID
  • TED diagnosis with ICD-10 code (H05.20x series)
  • Clinical Activity Score assessment (≥4/7 or ≥3/10)
  • Proptosis measurements and progression
  • Thyroid function labs within 30 days
  • Prior treatment history (steroids, radiation, surgery)
  • Functional impact on daily activities
  • Weight for dosing calculations

Supporting documents:

  • Baseline and current eye photos
  • Hertel exophthalmometry measurements
  • Thyroid function tests (TSH, T4, T3)
  • Documentation of steroid trial failure/contraindication
  • Quality of life assessment (GO-QOL if available)

Step 3: Submit Prior Authorization

Submission options:

  • Online: Humana provider portal (fastest)
  • CoverMyMeds: Electronic PA platform
  • Fax: Check current fax number via provider portal

Timeline: 72 hours to 14 days for standard review; request expedited if urgent (72 hours decision)

If "Possibly Eligible": Tests and Timeline

Additional Testing Needed

  1. Repeat CAS assessment with detailed photos and measurements
  2. Updated thyroid labs if >30 days old
  3. Ophthalmology consultation for complete VISA assessment (Vision, Inflammation, Strabismus, Appearance)
  4. Document functional impact with specific examples of limitations

30-Day Action Plan

  • Week 1: Schedule ophthalmology evaluation
  • Week 2: Complete thyroid function testing
  • Week 3: Gather prior treatment records
  • Week 4: Submit PA with comprehensive documentation

What to Track

  • Proptosis progression (≥2mm increase scores 1 CAS point)
  • New symptoms (pain, redness, swelling, vision changes)
  • Functional limitations (driving, reading, work impact)
  • Thyroid stability (trending toward euthyroid range)

If "Not Yet": Alternatives and Exceptions

Immediate Treatment Options

  • IV methylprednisolone for acute inflammatory phase
  • Oral prednisone (though less effective than Tepezza)
  • Selenium supplementation for mild cases
  • Supportive care (lubricants, prisms, protective eyewear)

Building Your Case for Future Approval

  1. Establish specialist care with ophthalmologist or endocrinologist
  2. Document disease progression with serial photos and measurements
  3. Trial appropriate therapies (steroids if not contraindicated)
  4. Optimize thyroid control to achieve euthyroid status

Exception Request Strategy

Even if not meeting standard criteria, you can request a formulary exception if:

  • All alternatives are medically contraindicated
  • Standard treatments have failed despite adequate trials
  • Tepezza is medically necessary for your specific case

Submit via Humana's Medicare Prescription Drug Coverage Determination form with detailed clinical rationale.

If Denied: New York Appeals Path

New York offers robust consumer protections with multiple appeal options and high success rates.

Level 1: Internal Appeal (Required First)

Timeline: File within 65 days of denial Decision: 7 days for standard; 72 hours for expedited How to file:

  • Online via Humana member portal
  • Phone: Member Services number on ID card
  • Written appeal with additional documentation

Level 2: External Review (New York DFS)

Timeline: Within 4 months of final internal denial Fee: $25 (waived for Medicaid/hardship; refunded if you win) Success rate: ~50-60% of denials overturned Process: File via NY DFS External Appeal portal

Required documents:

  • Final denial letter from Humana
  • All medical records and photos
  • Updated CAS assessment
  • Medical literature supporting Tepezza use
  • Provider letter of medical necessity

Expedited External Review

Available if delay would seriously jeopardize health:

  • Standard expedited: 72 hours
  • Drug denials: 24 hours
  • Requires physician attestation of urgency
From our advocates: "We've seen several Tepezza external appeals succeed in New York when patients included progression photos, detailed CAS documentation, and peer-reviewed studies showing Tepezza's superiority over steroids. The key is demonstrating active disease that's impacting daily function—not just meeting clinical criteria on paper."

Free Help Available

  • Community Health Advocates: 888-614-5400 (free counseling on appeals)
  • NY DFS Consumer Hotline: 1-800-342-3736 (filing assistance)

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for J3241 Humana PA Lists Humana
Medical Benefit Covered under Part B, not Part D Medicare Summary Notice CMS
CAS ≥4 Active inflammatory disease Ophthalmology exam Tepezza HCP Guide
Euthyroid Status Thyroid levels stable Lab results within 30 days FDA Label
Specialist Prescriber Ophthalmology/Endocrinology Provider directory Humana
Appeal Deadline 65 days from denial Denial letter Medicare
External Review 4 months from final denial NY DFS Portal NY DFS

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
"CAS not documented" Submit detailed CAS assessment 7-point CAS form with photos
"Not euthyroid" Show trending toward normal Serial thyroid labs over 3-6 months
"No prior therapy documented" Provide steroid trial records Prescription records, clinic notes
"Experimental/investigational" Cite FDA approval FDA Orange Book entry
"Not medically necessary" Demonstrate functional impact GO-QOL scores, work limitations
"Quantity/dosing issues" Clarify weight-based dosing Provider calculation worksheet

Costs and Financial Assistance

Humana Medicare Advantage (2025)

  • Deductible: Varies by plan ($0-$590)
  • Coinsurance: Typically 20% after deductible
  • Out-of-pocket maximum: $8,850 in-network
  • Estimated patient cost: $1,750-$10,000+ per infusion

Financial Assistance Options

  • Amgen By Your Side: Copay assistance (Medicare restrictions apply) - tepezza.com/cost-and-support
  • HealthWell Foundation: Grants for thyroid eye disease
  • Chronic Disease Fund: Copay assistance programs
  • Hospital charity care: Many infusion centers offer payment plans
Note: Medicare patients have limited copay assistance options due to federal anti-kickback laws, but foundations and hospital programs may help.

FAQ: Your Top Questions Answered

Q: How long does Humana prior authorization take in New York? A: Standard review is 72 hours to 14 days. Expedited requests (when health is at risk) get decisions within 72 hours. Submit complete documentation to avoid delays.

Q: What if Tepezza isn't on my Humana formulary? A: Tepezza is a medical benefit (J3241), not a pharmacy benefit, so formulary status doesn't apply. Prior authorization is still required under medical benefits.

Q: Can I get Tepezza if I've never tried steroids? A: Most plans require documented steroid failure or contraindication. If you can't take steroids due to diabetes, osteoporosis, or other conditions, document this clearly.

Q: What's the success rate for Tepezza appeals in New York? A: New York's external review program overturns ~50-60% of denials overall. Tepezza appeals with proper documentation have shown good success rates, including documented case 202211-155790.

Q: How do I prove my TED is "active" if symptoms seem stable? A: Focus on functional impact and any progression in measurements. Even stable disease can qualify if it significantly affects daily activities and standard treatments have failed.

Q: Can I appeal to New York DFS if I have an employer plan? A: Only if your employer plan is regulated by New York. Self-funded ERISA plans must use federal appeals processes, but many employer plans in New York do fall under state regulation.

When navigating complex prior authorizations and appeals, having expert support can make the difference between approval and denial. Counterforce Health helps patients and providers turn insurance denials into successful appeals by analyzing payer policies and crafting evidence-based rebuttals that speak directly to each plan's specific requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare providers and insurance company for personalized guidance. For additional help with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or the NY Department of Financial Services Consumer Hotline at 1-800-342-3736.

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