By Counterforce Health Team in Tepezza (teprotumumab) —

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

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

Tepezza (teprotumumab) requires prior authorization from Aetna CVS Health for thyroid eye disease (TED). You'll need documentation of moderate-to-severe TED, specialist evaluation, and prior treatment failures. If denied, California's Independent Medical Review (IMR) has a 73% success rate for overturning health plan denials. First step: Have your ophthalmologist or endocrinologist complete Aetna's Tepezza precertification form with comprehensive clinical documentation.

Table of Contents

  1. Is Tepezza Covered by Aetna CVS Health?
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Clinical Criteria and Documentation
  5. Cost Considerations
  6. Common Denial Reasons and Appeals
  7. California-Specific Appeal Rights
  8. Specialty Pharmacy Requirements
  9. Frequently Asked Questions
  10. Resources and Next Steps

Is Tepezza Covered by Aetna CVS Health?

Yes, Tepezza is covered by Aetna CVS Health under the medical benefit for FDA-approved thyroid eye disease (TED), but only with prior authorization and strict clinical criteria. The drug is billed using HCPCS code J3241 (10 mg per unit) and administered at approved infusion centers.

Coverage Requirements at a Glance:

Requirement Details Documentation Needed
Prior Authorization Always required Aetna precertification form
Age Limit 18+ years Date of birth verification
Specialist Requirement Ophthalmologist or endocrinologist Consultation notes
Diagnosis Moderate-to-severe TED Clinical Activity Score, photos
Step Therapy Prior treatment failures required Medication records
Lifetime Limit One course (8 infusions) Treatment plan

Aetna considers Tepezza experimental or investigational for any use outside of TED, which results in automatic denial.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Specialist Evaluation (Patient + Clinic)
    • Schedule with ophthalmologist or endocrinologist experienced in TED
    • Document Clinical Activity Score (CAS), proptosis measurements, photos
    • Timeline: 1-2 weeks for appointment
  2. Gather Required Documentation (Clinic)
    • Complete medical records showing TED diagnosis
    • Prior treatment history and failures
    • Thyroid function tests (within 2 months)
    • Timeline: 3-5 business days
  3. Submit Prior Authorization (Clinic)
  4. Aetna Review (Automated)
    • Standard review: 15-30 business days
    • Expedited (urgent): 72 hours
    • Timeline: Varies by urgency
  5. Approval and Coordination (Patient + Clinic)
    • Coordinate with CVS Caremark Specialty Pharmacy
    • Schedule infusion center appointments
    • Timeline: 1-2 weeks for first infusion

Timeline and Urgency

Standard prior authorization decisions: 15-30 business days from complete submission

Expedited reviews are available for urgent medical situations and must be decided within 72 hours. To request expedited review, the prescriber must document that waiting for standard review could:

  • Seriously jeopardize your health
  • Jeopardize your ability to regain maximum function
  • Subject you to severe pain that cannot be adequately managed

California-specific timing: If Aetna fails to respond within required timeframes, you can file a complaint with the California Department of Managed Health Care at 888-466-2219.

Clinical Criteria and Documentation

Aetna requires comprehensive documentation to prove medical necessity for Tepezza:

Required Clinical Criteria

Diagnosis Requirements:

  • Confirmed thyroid eye disease (TED) diagnosis
  • Moderate-to-severe disease activity
  • Clinical Activity Score (CAS) documentation
  • Proptosis measurements and photos

Step Therapy Requirements: Patients must have tried and failed, or have contraindications to:

  • Conservative measures (eye drops, cool compresses, head elevation)
  • Oral corticosteroids (prednisone) or IV methylprednisolone
  • Antithyroid medications if hyperthyroid

Laboratory Requirements:

  • Thyroid function tests showing euthyroid or mildly abnormal status
  • For diabetic patients: HbA1c ≤ 9% for glycemic control

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements for Your Letter:Patient's TED diagnosis with ICD-10 codes (H05.20, H05.21, E05.00, E05.01)Detailed description of disease severity and impact on vision/quality of lifeComplete history of prior treatments tried, dosages, duration, and reasons for failure/discontinuationClinical rationale citing FDA approval for TEDWeight-based dosing plan (10 mg/kg once, then 20 mg/kg × 7 infusions)Monitoring plan for infusion reactions, hyperglycemia, and hearing changes

Cost Considerations

Tepezza is covered under Aetna's medical benefit, not pharmacy benefit, which typically means:

  • Coinsurance (percentage) rather than flat copays
  • Costs vary significantly by plan type and deductible status
  • Full treatment course can cost $350,000-$500,000+ in drug costs alone

Financial Assistance Options

Manufacturer Support:

  • Amgen By Your Side patient support program
  • Copay assistance for eligible patients
  • Patient enrollment forms available through prescriber

Other Resources:

  • Foundation grants for rare disease treatments
  • State pharmaceutical assistance programs
  • Hospital charity care programs

Contact your clinic's financial counselor to explore all options before starting treatment.

Common Denial Reasons and Appeals

Most Common Aetna Denial Reasons

Denial Reason How to Overturn Required Documentation
Experimental/Investigational Emphasize FDA approval for TED FDA label, clinical guidelines
Step therapy not met Document all prior treatments Medication records, specialist notes
Insufficient severity Provide detailed clinical assessment CAS scores, proptosis measurements, photos
Missing specialist evaluation Obtain ophthalmology/endocrinology consult Consultation notes, treatment recommendations
Incomplete documentation Submit comprehensive medical records All required forms and supporting documents

Internal Appeals Process

  1. File within 180 days of denial notification
  2. Submit additional documentation addressing specific denial reasons
  3. Request peer-to-peer review if available
  4. Standard appeal timeline: 30 days for decision
  5. Expedited appeals: 72 hours for urgent situations

California-Specific Appeal Rights

California offers some of the strongest patient appeal rights in the nation through the Department of Managed Health Care (DMHC).

Independent Medical Review (IMR) Success Rate

California IMR statistics show a 73% success rate for patients who file Independent Medical Reviews, with medical necessity appeals showing even higher success rates of approximately 76% for major insurers like Aetna.

How to Request California IMR

  1. Complete internal appeal with Aetna first (required)
  2. File IMR application within 6 months of final internal denial
  3. Submit through DMHC: Online at healthhelp.ca.gov or call 888-466-2219
  4. No cost to patient - insurers pay for the review
  5. Timeline: Standard IMR decided within 45 days; expedited within 7 days
  6. Binding decision: Aetna must comply with IMR approval
From our advocates: "We've seen several California patients successfully overturn Tepezza denials through IMR by emphasizing the FDA approval, documenting failed steroid therapy, and including detailed ophthalmology notes showing disease progression. The key is comprehensive clinical documentation that directly addresses the plan's stated denial reasons."

DMHC Contact Information

Specialty Pharmacy Requirements

Aetna typically requires Tepezza to be dispensed through CVS Caremark Specialty Pharmacy and administered at approved infusion centers.

What to Expect

  1. Automatic transfer from retail pharmacy to specialty pharmacy
  2. Coordination required between specialty pharmacy and infusion center
  3. Scheduling assistance for infusion appointments
  4. Cold-chain shipping directly to infusion center
  5. Clinical monitoring throughout treatment course

CVS Caremark Specialty contact: Available through your Aetna member portal or by calling the number on your insurance card.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in California? Standard review takes 15-30 business days. Expedited review for urgent situations is completed within 72 hours.

What if Tepezza is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. If denied, California's IMR process can review non-formulary denials.

Can I request an expedited appeal in California? Yes, both Aetna internal appeals and California IMR can be expedited if delay would seriously jeopardize your health or subject you to severe pain.

Does step therapy apply if I failed treatments in another state? Yes, prior treatment history from other states counts toward fulfilling Aetna's step therapy requirements. Ensure your new California provider has complete medical records.

What happens if I need a second course of Tepezza? Aetna typically approves only one lifetime course (8 infusions). Additional treatment would require exceptional circumstances and strong clinical justification.

How do I check my prior authorization status? Log into your Aetna member portal or call member services. Providers can check status through the Aetna provider portal or by calling 1-866-752-7021.

Resources and Next Steps

For patients seeking coverage help, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeal processes for specialty medications like Tepezza.

Essential Forms and Contacts

Next Steps Checklist

  • Schedule appointment with ophthalmologist or endocrinologist
  • Gather documentation of prior treatments and failures
  • Obtain current thyroid function tests
  • Complete clinical severity assessments (CAS, proptosis, photos)
  • Submit comprehensive prior authorization request
  • If denied, file internal appeal within 180 days
  • If internal appeal fails, request California IMR within 6 months

Remember: Counterforce Health can help streamline this process by analyzing your specific situation and creating targeted appeal strategies based on your plan's policies and denial reasons.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by your health plan based on your specific policy and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For assistance with California insurance complaints or appeals, contact the DMHC Help Center at 888-466-2219.

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