By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Approved by Aetna CVS Health in Georgia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Tepezza Covered by Aetna CVS Health in Georgia

Aetna covers Tepezza (teprotumumab) for thyroid eye disease under medical benefit with prior authorization requiring moderate-to-severe TED, ophthalmologist prescription, and documented steroid failures. Submit PA via Aetna provider portal with Clinical Activity Score ≥4, recent thyroid labs, and treatment history. If denied, appeal within 180 days internally, then request Georgia DOI external review within 60 days. Start today: Contact your ophthalmologist to complete Aetna's Tepezza precertification form and gather required documentation.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. If You Need More Information
  7. If Your Request is Denied
  8. Appeals Process in Georgia
  9. Renewal and Re-Authorization
  10. Cost Support Options
  11. Frequently Asked Questions

What This Guide Covers

This guide helps Georgia patients and their healthcare providers navigate Aetna CVS Health's prior authorization process for Tepezza (teprotumumab-trbw), a specialized infusion therapy for thyroid eye disease (TED). Whether you're dealing with an initial request, denial, or appeal, you'll find step-by-step instructions, required forms, and Georgia-specific timelines.

Who this helps:

  • Patients with moderate-to-severe thyroid eye disease
  • Ophthalmologists and endocrinologists prescribing Tepezza
  • Specialty pharmacies coordinating infusion therapy
  • Caregivers advocating for coverage

Before You Start: Verify Your Coverage

Check Your Plan Type and Benefits

Medical vs. Pharmacy Benefit: Tepezza is covered under Aetna's medical benefit (not pharmacy benefit) because it's administered via IV infusion in clinical settings. This means your medical deductible and coinsurance apply, not pharmacy copays.

Verify these details:

  • Confirm you have Aetna CVS Health coverage (check your member ID card)
  • Ensure your ophthalmologist is in-network with Aetna
  • Check if your plan requires referrals for specialty care
  • Verify infusion center is Aetna-contracted
Tip: Call the member services number on your insurance card to confirm Tepezza coverage and any plan-specific requirements before starting the PA process.

Formulary Status and Requirements

Tepezza requires prior authorization on all Aetna plans and is limited to one lifetime course of 8 infusions. The medication is not subject to step therapy for the FDA-approved indication of thyroid eye disease, but you must demonstrate medical necessity through clinical documentation.

Gather Required Documentation

Essential Clinical Information

Document Type Specific Requirements Where to Obtain
TED Diagnosis ICD-10 codes H05.20/H05.21 (TED), E05.00/E05.01 (Graves') Ophthalmologist records
Disease Severity Clinical Activity Score (CAS) ≥4 for active disease, proptosis measurements Eye exam notes
Thyroid Status TSH, free T4 within 30 days showing euthyroid or stable Lab results
Prior Treatments Documentation of steroid trial/failure or contraindications Treatment records
Clinical Photos Before/after images showing TED severity Ophthalmologist office

Medical Necessity Letter Components

Your ophthalmologist's medical necessity letter must include:

  1. Patient demographics and confirmed TED diagnosis
  2. Disease severity indicators: CAS score, proptosis measurements, functional impact
  3. Prior treatment history: Steroids tried, doses, duration, outcomes, or contraindications
  4. Treatment rationale: Why Tepezza is medically necessary for this patient
  5. Dosing plan: Weight-based dosing (10 mg/kg initial, then 20 mg/kg × 7)
  6. Monitoring plan: Infusion reactions, glucose monitoring, hearing assessment

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Complete Aetna's Tepezza Precertification Form

  • Download from Aetna's provider portal (verify current link)
  • Required fields include patient demographics, diagnosis codes, prescriber information

2. Compile Supporting Documentation

  • Medical necessity letter from ophthalmologist
  • Clinical notes showing TED severity and impact
  • Lab results (thyroid function tests)
  • Prior treatment records or contraindication documentation
  • Clinical photographs if available

3. Submit via Preferred Method

  • Online: Aetna provider portal (fastest processing)
  • Fax: 1-888-267-3277 (verify current number with Aetna)
  • Phone: 1-866-752-7021 for urgent requests

4. Obtain Confirmation

  • Request reference number for tracking
  • Confirm receipt within 24-48 hours
  • Document submission date and contact information
Note: CVS Caremark handles specialty pharmacy coordination but prior authorization must go through Aetna's medical benefit team, not pharmacy.

Follow-Up and Timeline Expectations

Standard Processing Times

  • Initial review: 5-10 business days
  • Additional information requests: 3-5 business days to respond
  • Final determination: Up to 30 calendar days total
  • Expedited requests: 72 hours if urgent medical need

When and How to Follow Up

Call Aetna at 1-800-872-3862 (member services) if:

  • No response after 10 business days
  • Additional information requested
  • Status changes needed due to clinical urgency

Sample follow-up script: "I'm calling to check the status of a Tepezza prior authorization for [patient name], member ID [number], submitted on [date]. The reference number is [if available]. Can you provide the current status and any additional requirements?"

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting targeted, evidence-backed rebuttals aligned to each plan's own rules. Their platform can help streamline the prior authorization process by ensuring all required documentation is properly formatted and submitted according to Aetna's specific requirements.

If You Need More Information

Common Information Requests

Clinical clarification requests typically ask for:

  • More detailed CAS scoring methodology
  • Specific contraindications to steroid therapy
  • Weight-based dosing calculations
  • Timeline for treatment course completion

How to respond effectively:

  1. Submit within the requested timeframe (usually 10-14 days)
  2. Be specific and quantitative in your responses
  3. Reference FDA labeling and clinical guidelines
  4. Include peer-reviewed literature supporting off-label uses if applicable

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient severity documentation Submit detailed CAS scores and functional impact Standardized CAS assessment, visual field tests
No prior steroid trial Document contraindications or previous failures Allergy records, treatment history, adverse events
Not euthyroid Provide recent labs showing stable thyroid function TSH/T4 within 30 days, endocrinology consult
Experimental/investigational Cite FDA approval and clinical guidelines FDA labeling, ATA guidelines, peer-reviewed studies

Immediate Next Steps After Denial

  1. Request detailed denial letter with specific reasons
  2. Review Aetna's medical policy for Tepezza criteria
  3. Gather additional evidence addressing denial reasons
  4. Consider peer-to-peer review before formal appeal
  5. File internal appeal within 180 days

Appeals Process in Georgia

Internal Appeal (First Level)

Timeline: 180 calendar days from denial date for medical necessity disputes

How to file:

  • Use Aetna appeal form (download from provider portal)
  • Submit via Availity portal, mail, or fax
  • Include all original documentation plus rebuttal evidence

Required elements:

  • Original denial letter/EOB
  • Updated medical records addressing denial reasons
  • Prescriber letter specifically rebutting denial points
  • Clinical literature supporting medical necessity

External Review (Georgia DOI)

If your internal appeal is denied, Georgia residents can request an independent external review through the Georgia Department of Insurance.

Critical timeline: 60 days from final internal denial (shorter than federal requirements)

How to request:

  1. Contact Georgia DOI at 1-800-656-2298
  2. Submit free application for external review
  3. Include all documentation from internal appeal process
  4. Request expedited review if medically urgent (72-hour decision)

What happens next:

  • Independent physicians review your case
  • Decision is binding on Aetna
  • Standard review completed within 30 business days
  • Expedited review completed within 72 hours if urgent
Georgia-specific advantage: External review decisions are legally binding on insurers, providing strong consumer protection for wrongful denials.

Renewal and Re-Authorization

Important Limitations

One-time treatment: Aetna limits Tepezza to one lifetime course of 8 infusions. No repeat courses are covered, and re-authorization requests are typically denied unless there are exceptional circumstances.

Documentation for completion:

  • Track all 8 infusion dates
  • Document clinical response and outcomes
  • Report any adverse events or treatment modifications
  • Maintain records for potential future appeals of related treatments

Cost Support Options

Financial Assistance Programs

Amgen Co-Pay Program:

Foundation Grants:

  • Patient advocate organizations may provide assistance
  • Georgia residents can contact Georgians for a Healthy Future for guidance
  • Legal aid through Georgia Legal Services Program for complex cases

Understanding Your Costs

  • Drug cost: ~$350,000-$500,000 for full 8-infusion course
  • Administration fees: Additional charges for infusion center services
  • Your responsibility: Depends on deductible, coinsurance, and out-of-pocket maximum

Frequently Asked Questions

Q: How long does Aetna prior authorization take in Georgia? A: Standard processing is up to 30 calendar days, but most decisions are made within 10-15 business days. Expedited requests for urgent medical situations are processed within 72 hours.

Q: What if Tepezza is non-formulary on my plan? A: Tepezza requires prior authorization on all Aetna plans but is not typically excluded. If listed as non-formulary, request a formulary exception with medical necessity documentation.

Q: Can I get temporary coverage while my appeal is pending? A: Aetna may provide temporary coverage during expedited appeals if there's urgent medical need. This varies by plan type and clinical circumstances.

Q: Does step therapy apply if I tried steroids outside Georgia? A: Treatment history from any location counts toward step therapy requirements. Provide documentation of previous steroid trials regardless of where they occurred.

Q: What happens if I miss an infusion due to insurance delays? A: Contact your ophthalmologist immediately to discuss clinical implications. Document any treatment delays caused by insurance issues for potential appeals or complaints.

Q: Who can prescribe Tepezza for Aetna coverage? A: Aetna typically requires prescription by or consultation with an ophthalmologist. Some plans may accept endocrinology prescriptions with appropriate TED expertise documentation.

When navigating complex prior authorization requirements, Counterforce Health can help by analyzing denial letters and crafting targeted appeals that address specific payer criteria. Their platform identifies the exact denial basis and provides evidence-backed rebuttals aligned to Aetna's own coverage rules.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual plan terms, clinical circumstances, and current policies. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals, contact the Georgia Department of Insurance or consider working with patient advocacy organizations.

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