By Counterforce Health Team in Tepezza (teprotumumab) —

Get Tepezza (Teprotumumab) Covered by UnitedHealthcare in North Carolina: Forms, Appeals & Step-by-Step Guide

Answer Box: Your Fastest Path to Approval

To get Tepezza (teprotumumab) covered by UnitedHealthcare in North Carolina, you need prior authorization with specific clinical documentation. Submit your PA request through the UnitedHealthcare Provider Portal or use the North Carolina-specific pharmacy prior authorization form. Required: moderate-to-severe thyroid eye disease diagnosis by an ophthalmologist/endocrinologist, Clinical Activity Score ≥3, proptosis measurements ≥3mm, euthyroid status, and documented corticosteroid trial failure. If denied, you have 180 days for internal appeals, then 120 days for external review through North Carolina's Smart NC program.

First step today: Verify your UnitedHealthcare plan type and download the current PA form from the NC-specific forms portal.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Requirements
  3. Submission Portals & Methods
  4. Specialty Pharmacy Enrollment
  5. Appeals Process: Internal & External
  6. Common Denial Reasons & Solutions
  7. North Carolina Consumer Resources
  8. Cost Support Options
  9. FAQ

1. Verify Your Plan & Find the Right Forms

Before starting your Tepezza prior authorization, confirm your specific UnitedHealthcare plan type. Different plans (commercial, Medicare Advantage, Medicaid) may have slightly different requirements and forms.

Current PA Forms for North Carolina:

Tip: Search for "Tepezza" in the forms portal. If no drug-specific form appears, use the generic North Carolina prior authorization request form.

2. Prior Authorization Requirements

UnitedHealthcare requires comprehensive clinical documentation for Tepezza approval. Based on their current medical policy, you must meet all criteria below:

Coverage Requirements Table

Requirement Details Documentation Needed
Diagnosis Moderate-to-severe thyroid eye disease ICD-10 codes (E05.00, H06.2*)
Prescriber Ophthalmologist or endocrinologist Specialty verification
Clinical Activity Score CAS ≥3 out of 7 points Detailed CAS breakdown
Proptosis ≥3mm above normal OR ≥3mm increase from baseline Measurements in mm
Thyroid Status Euthyroid (normal function tests) TSH, free T3, free T4 within 30 days
Prior Treatment Failed corticosteroid trial or contraindication Treatment history with dates/outcomes
Age 18 years or older Date of birth verification
Maximum Dose 8 infusions per lifetime Treatment plan with infusion schedule

Required Clinical Documentation

Your submission must include:

  • Complete medical history and physical exam notes
  • Ophthalmologic evaluation with proptosis measurements
  • Clinical Activity Score assessment (detail each of 7 criteria)
  • Laboratory results: recent thyroid function tests
  • Prior treatment records showing steroid trial failure or contraindications
  • Proposed dosing schedule (typical: 10 mg/kg once, then 20 mg/kg × 7 infusions)
  • HCPCS billing code: J3241 (10 mg units)

3. Submission Portals & Methods

Electronic Submission (Preferred)

UnitedHealthcare Provider Portal:

  • Log in at UHCprovider.com
  • Navigate to Prior Authorization section
  • Upload all required documents
  • Track status in real-time

Third-Party Portals:

  • CoverMyMeds: Electronic PA submission
  • SureScripts: Integrated with many EHR systems

Fax Submission

If electronic submission isn't available:

  • General Medical/Community Plan: 800-267-8328
  • Pharmacy Prior Authorization: 866-940-7328
  • Include complete clinical documentation package
  • Use cover sheet with patient ID and drug name

Processing Timelines

  • Standard review: 15 business days
  • Expedited/urgent: 72 hours (requires clinical justification)
  • Status check: Call 888-887-9003 or check provider portal

4. Specialty Pharmacy Enrollment

Tepezza requires specialty pharmacy coordination through UnitedHealthcare's network, typically OptumRx Specialty Pharmacy.

Enrollment Process

  1. Complete PA approval first (required before specialty pharmacy enrollment)
  2. Provider enrollment: Submit Tepezza Patient Enrollment Form
  3. Fax to: 1-833-469-8333
  4. Email to: [email protected]
  5. Support line: 1-833-583-7399 (Amgen By Your Side)

Required Information

  • Signed patient consent and HIPAA authorization
  • Prescriber details and DEA number
  • Insurance verification
  • Infusion site coordination
  • Weight-based dosing calculations

At Counterforce Health, we help patients and clinicians streamline this complex enrollment process by ensuring all documentation meets UnitedHealthcare's specific requirements and coordinating between the specialty pharmacy, infusion center, and insurance approval—reducing delays and preventing common submission errors.

5. Appeals Process: Internal & External

If your Tepezza prior authorization is denied, North Carolina offers robust appeal rights with specific timelines.

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial date Levels: Typically 1-2 internal review levels Submission: Provider portal, fax, or mail as specified in denial letter

Required for Appeal:

  • Copy of original denial letter
  • Additional clinical evidence addressing denial reasons
  • Updated medical necessity letter
  • Supporting literature or guidelines

External Review Through Smart NC

North Carolina's external review program offers independent review after internal appeals are exhausted.

Key Details:

  • Deadline: 120 days from final internal denial
  • Cost: Free to patients
  • Contact: Smart NC at 1-855-408-1212
  • Standard timeline: 45 days for decision
  • Expedited timeline: 3 days for urgent cases

How to File:

  1. Complete External Review Request Form
  2. Include all medical records and denial letters
  3. Submit to NC Department of Insurance
  4. Independent Review Organization makes binding decision
Note: Smart NC staff provide free assistance with completing forms and gathering documentation. About 45% of external reviews overturn initial denials.

6. Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient CAS documentation Provide detailed 7-point CAS breakdown Individual scoring for each criterion
Missing proptosis measurements Submit ophthalmologic measurements Baseline and current measurements in mm
Inadequate prior therapy documentation Document steroid trial details Dates, doses, duration, outcomes, side effects
Euthyroid status not confirmed Submit recent thyroid function tests TSH, free T3, free T4 within 30 days
Non-specialty prescriber Transfer to ophthalmologist/endocrinologist Specialty verification and evaluation
Coding errors Correct HCPCS billing Use J3241 with proper unit calculations

7. North Carolina Consumer Resources

Smart NC Consumer Assistance

North Carolina provides exceptional consumer protection for insurance appeals:

Services Available:

  • Free appeal assistance and form completion
  • Medical record gathering support
  • Communication with insurers
  • Educational resources and sample letters

Contact Information:

When to Contact Smart NC

  • Your internal appeal was denied
  • You need help understanding denial reasons
  • You're approaching appeal deadlines
  • You need assistance gathering medical records

8. Cost Support Options

Manufacturer Support Programs

Amgen By Your Side:

  • Patient enrollment assistance
  • Insurance navigation support
  • Copay assistance for eligible patients
  • Phone: 1-833-583-7399
  • Website: Amgen By Your Side

Financial Assistance

  • Copay cards: May reduce out-of-pocket costs for commercially insured patients
  • Patient assistance programs: For uninsured or underinsured patients
  • Foundation grants: Various rare disease foundations offer medication assistance
From our advocates: "We've seen cases where patients initially faced $15,000+ annual out-of-pocket costs get reduced to under $100/month through manufacturer copay programs combined with successful appeals. The key is applying for financial assistance programs early in the process, even before PA approval."

9. FAQ

How long does UnitedHealthcare PA take in North Carolina? Standard prior authorization takes up to 15 business days. Expedited reviews for urgent medical need are completed within 72 hours.

What if Tepezza is non-formulary on my plan? Non-formulary drugs can still be covered through medical exception processes. Submit clinical documentation showing medical necessity and lack of formulary alternatives.

Can I request an expedited appeal? Yes, if waiting would jeopardize your health. Provide physician documentation of urgent medical need. North Carolina's expedited external review provides decisions within 3 days.

Does step therapy apply if I've failed steroids outside North Carolina? Yes, UnitedHealthcare accepts prior therapy documentation from any provider. Include complete treatment records with dates, doses, and outcomes.

What happens if my external review is approved? UnitedHealthcare must provide coverage within 3 business days of the external review decision. The decision is binding on the insurer.

How much does Tepezza cost without insurance? Current wholesale cost is approximately $17,511 per 500mg vial. A full 8-infusion course typically costs $350,000-$500,000+ depending on patient weight and dosing requirements.

Counterforce Health specializes in turning insurance denials into successful appeals through evidence-based advocacy. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts targeted rebuttals that align with each payer's requirements—helping patients access critical medications like Tepezza more efficiently.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage details. Coverage criteria and processes may change—verify current requirements with official sources before submitting requests.

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