By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Aetna CVS Health in Illinois: Prior Authorization Forms, Appeals Process, and Alternative Options

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

Tepezza (teprotumumab) requires prior authorization from Aetna CVS Health in Illinois. You'll need documentation of moderate-to-severe thyroid eye disease, failure or contraindication to corticosteroids, and ophthalmology consultation. If denied, Illinois law provides strong appeal rights including independent external review within 30 days. First step today: Have your ophthalmologist gather clinical photos, proptosis measurements, and documentation of failed steroid therapy, then submit the PA request through Aetna's provider portal or by fax to 1-866-249-6155.

Table of Contents

  1. Coverage Requirements at a Glance
  2. When Alternatives Make Sense
  3. Typical Alternatives to Tepezza
  4. Pros and Cons of Each Option
  5. Exception Strategy: When to Request Tepezza
  6. Step-by-Step: Fastest Path to Approval
  7. Appeals Playbook for Illinois
  8. Common Denial Reasons & Solutions
  9. Switching Back to Tepezza Later
  10. Cost Assistance Programs
  11. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before treatment Aetna provider portal or fax 1-866-249-6155 Aetna Precert List
Step Therapy Must try corticosteroids first Document failure/intolerance in PA request Aetna Tepezza Policy
Ophthalmology Consultation Specialist must prescribe or co-manage Include consultation notes in submission Aetna Medical Policy
Medical Benefit Coverage Covered under medical, not pharmacy Billed with J-code J3241 CMS HCPCS
Appeals Deadline (Illinois) 30 days for external review Count from final denial date Illinois DOI

When Alternatives Make Sense

Before pursuing Tepezza, consider whether alternatives might be appropriate for your situation. Aetna CVS Health requires documented failure or contraindication to corticosteroids before approving Tepezza, making this step therapy requirement unavoidable for most patients.

Alternatives may be preferable when:

  • You have mild-to-moderate thyroid eye disease that hasn't progressed significantly
  • Corticosteroids haven't been tried yet (required by most insurance plans)
  • Cost is a primary concern (alternatives are typically much less expensive)
  • You have contraindications to Tepezza (such as inflammatory bowel disease or hearing problems)
Note: Tepezza is the only FDA-approved medication specifically for thyroid eye disease, but clinical guidelines recognize several effective alternatives for managing symptoms and disease progression.

Typical Alternatives to Tepezza

First-Line Treatments (Required by Aetna)

Oral Corticosteroids (Prednisone)

  • Mechanism: Reduces inflammation behind the eyes
  • Typical dosing: High initial dose (60-100mg daily) tapered over 3-6 months
  • Coverage: Generally covered on formulary with minimal restrictions

Intravenous Methylprednisolone

  • Mechanism: More targeted anti-inflammatory effect with potentially fewer systemic side effects
  • Administration: Weekly IV pulses, typically 12 treatments
  • Coverage: Covered under medical benefit, may require PA for site of care

Second-Line Options

Rituximab

  • Mechanism: B-cell depleting agent that modulates immune response
  • Evidence: Studies show effectiveness comparable to IV steroids in some patients
  • Coverage: Requires PA and documentation of steroid failure

Tocilizumab (Actemra)

  • Mechanism: IL-6 receptor antagonist
  • Use: Acceptable for glucocorticoid-resistant patients
  • Coverage: Step therapy required after steroid failure

Supportive Therapies

Selenium Supplementation

  • Evidence: May slow disease progression and improve quality of life
  • Coverage: Generally not covered as prescription therapy
  • Cost: Available over-the-counter for $10-30/month

Pros and Cons of Each Option

Treatment Pros Cons Access Considerations
Tepezza Only FDA-approved drug; superior proptosis reduction Very expensive ($350k+ per course); hearing loss risk Requires extensive PA documentation
Oral Steroids Readily available; well-studied; inexpensive Significant side effects; weight gain; mood changes Usually first-line requirement
IV Methylprednisolone Fewer systemic effects than oral steroids Requires IV access; time-intensive May need site-of-care approval
Rituximab Effective second-line option Limited TED-specific data; infection risk Requires hematology/rheumatology consultation
Selenium Safe; inexpensive; easy to take Limited efficacy data; not covered Over-the-counter availability

Exception Strategy: When to Request Tepezza

Strong Cases for Direct Tepezza Approval:

  • Documented contraindications to corticosteroids (active infections, uncontrolled diabetes, severe osteoporosis, psychiatric contraindications)
  • Previous severe adverse reactions to steroids with clear documentation
  • Compressive optic neuropathy requiring urgent intervention
  • Moderate-to-severe TED with significant functional impairment

Documentation That Strengthens Your Case:

  • Clinical photos showing proptosis and lid retraction
  • Proptosis measurements (normal: <20mm; significant: >24mm)
  • Clinical Activity Score (CAS) ≥4 out of 7
  • Diplopia assessment and impact on daily activities
  • Thyroid function tests showing euthyroid status

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with each plan's specific requirements.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: Patient and ophthalmologist Documents needed: Insurance card, recent thyroid function tests, clinical photos, proptosis measurements Timeline: 1-2 weeks to collect everything

2. Document Prior Therapy Attempts

Who does it: Ophthalmologist or endocrinologist What to include: Specific steroids tried, doses, duration, response, and reasons for discontinuation Source: Aetna PA requirements

3. Complete Prior Authorization Form

Who does it: Prescribing physician How to submit: Aetna provider portal (Availity) or fax to 1-866-249-6155 Timeline: Standard decision within 72 hours of complete submission

4. Include Clinical Justification Letter

Key elements: Diagnosis with ICD-10 codes, severity assessment, functional impact, medical necessity rationale Supporting evidence: FDA labeling, clinical guidelines, peer-reviewed studies

5. Follow Up on Decision

Timeline: Aetna typically responds within 3-5 business days Next steps: If approved, coordinate with specialty pharmacy; if denied, immediately begin appeal process

Clinician Corner: Medical necessity letters should specifically address why corticosteroids are inappropriate or have failed, include objective measurements (proptosis in mm, CAS scores), and reference the FDA indication that Tepezza is approved for TED "regardless of activity or duration."

Appeals Playbook for Illinois

Illinois residents have particularly strong appeal rights under the Health Carrier External Review Act. Here's your roadmap:

Internal Appeal (First Level)

Deadline: File within 180 days of denial How to file: Call Aetna member services or submit written appeal Decision timeline: 15 business days for pre-service requests Required documents: Denial letter, additional clinical documentation, provider support letter

External Review (Independent)

Deadline: 30 days from final internal denial (shorter than most states) How to file: Request form from Illinois Department of Insurance at 877-527-9431 Decision timeline: 5 business days after IRO receives all materials Cost: Free to consumers (insurer pays IRO fees) Binding: Yes - if overturned, Aetna must cover treatment

Expedited Appeals

When to use: If delay would seriously jeopardize health (compressive optic neuropathy) Timeline: 24-72 hours for decision How to request: Call Aetna and specifically request "expedited appeal"

Illinois Advantage: The state's Attorney General Health Care Helpline (1-877-305-5145) can intervene informally with insurers and help gather supporting evidence for complex cases.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Document steroid failure/contraindication Chart notes showing adverse effects or medical contraindications
"Not medically necessary" Provide clinical evidence and guidelines FDA labeling, ophthalmology society guidelines, severity measurements
"Experimental/investigational" Cite FDA approval and clinical data FDA approval letter, published efficacy studies
"Non-formulary" Request formulary exception Medical necessity letter explaining why alternatives inadequate
"Insufficient documentation" Submit complete clinical picture Photos, measurements, lab results, consultation notes

Switching Back to Tepezza Later

If you try alternatives first and they don't work, switching back to Tepezza requires careful documentation:

Document Treatment Failure:

  • Specific alternative tried (drug, dose, duration)
  • Objective measures of lack of improvement (unchanged proptosis, persistent diplopia)
  • Side effects or intolerances experienced
  • Current disease status and functional impact

Re-Authorization Requirements:

  • Updated ophthalmology assessment within 90 days
  • Current thyroid function tests
  • Confirmation that TED remains active or has progressed
  • Clear rationale for why Tepezza is now appropriate

Most insurers limit Tepezza to one lifetime course, so switching back typically requires compelling evidence of disease relapse or new indications.

Cost Assistance Programs

Manufacturer Support:

  • Tepezza By Your Side offers copay assistance and patient navigation
  • May cover up to $10,000 per infusion for eligible patients
  • Free benefits investigation and prior authorization support

Foundation Assistance:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)
  • Income and diagnosis requirements vary

State Programs:

  • Illinois residents may qualify for state pharmaceutical assistance programs
  • Contact Illinois Department of Healthcare and Family Services for Medicaid coverage options

When working with complex prior authorizations and appeals, Counterforce Health helps patients and clinicians by ingesting denial letters and plan policies to create targeted rebuttals that address each payer's specific criteria and procedural requirements.

FAQ

Q: How long does Aetna CVS Health prior authorization take in Illinois? A: Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests for urgent cases can be decided within 24 hours.

Q: What if Tepezza is non-formulary on my plan? A: You can request a formulary exception by demonstrating medical necessity and that covered alternatives are inadequate. Include detailed clinical justification from your ophthalmologist.

Q: Can I appeal if I live in Illinois but have coverage from another state? A: Appeal rights depend on where your plan is regulated, not where you live. However, Illinois residents can contact the Illinois Department of Insurance for assistance regardless of plan origin.

Q: Does step therapy apply if I failed steroids in another state? A: Yes, documented steroid failure from any location should satisfy step therapy requirements. Ensure all records are included in your PA submission.

Q: How much does Tepezza cost without insurance? A: The wholesale acquisition 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.

Q: What happens if my appeal is denied? A: In Illinois, you can request an independent external review within 30 days. This involves a board-certified physician reviewer with TED expertise who can overturn the insurer's decision.

Q: Can I get Tepezza at home or only in a clinic? A: Tepezza requires IV infusion with monitoring for infusion reactions. Most insurers require administration in a qualified healthcare facility, though some may approve home infusion services.

Q: Is there a generic version of Tepezza available? A: No, Tepezza (teprotumumab) is still under patent protection. No generic or biosimilar versions are currently available.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with insurance appeals in Illinois, contact the Illinois Department of Insurance Office of Consumer Health Insurance at 877-527-9431.

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