By Counterforce Health Team in Tepezza (teprotumumab) —

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

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

Fastest path to approval: Aetna CVS Health requires prior authorization for Tepezza (teprotumumab) in Ohio. You need moderate-to-severe thyroid eye disease documentation, euthyroid status, and specialist involvement. Submit the PA form with complete clinical records through your provider. If denied, you have 180 days to appeal internally, then request external review through the Ohio Department of Insurance. Start today: Verify your plan covers specialty drugs under medical benefits and confirm your ophthalmologist or endocrinologist can prescribe.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Key Verifications
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Management
  6. If You Need to Provide Additional Information
  7. If Your Request Is Denied
  8. Understanding Renewal Requirements
  9. Appeals Process in Ohio
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps Ohio residents navigate the prior authorization process for Tepezza (teprotumumab) through Aetna CVS Health. Whether you're a patient newly diagnosed with thyroid eye disease or a clinician helping patients access this specialized treatment, you'll find step-by-step instructions, required forms, and proven strategies for overcoming denials.

Tepezza is the only FDA-approved treatment for thyroid eye disease (TED), offering significant improvements in eye bulging (proptosis) and quality of life. However, with treatment costs often exceeding $350,000-$500,000 for the full 8-infusion course, insurance approval is essential.

Who this helps: Ohio patients with Aetna CVS Health coverage (commercial, Medicare Advantage, or Medicaid managed care), their caregivers, and healthcare providers seeking Tepezza approval.

Before You Start: Key Verifications

Confirm Your Plan Type and Benefits

Step 1: Check if Tepezza is covered under medical benefits

  • Call the number on your Aetna member ID card
  • Ask: "Is Tepezza (teprotumumab, J-code J3241) covered under my medical benefits?"
  • Verify if CVS Specialty Pharmacy handles your specialty medications

Step 2: Confirm formulary status

  • Request your plan's specialty drug formulary
  • Look for Tepezza's tier placement and any restrictions
  • Note: Most Aetna plans classify Tepezza as a specialty medication requiring prior authorization

Step 3: Verify in-network providers

  • Ensure your ophthalmologist or endocrinologist is in-network
  • Confirm the infusion center where you'll receive treatment accepts your Aetna plan
  • For buy-and-bill scenarios, verify the provider can submit J3241 claims

Gather Required Documentation

Coverage Requirements for Tepezza in Ohio (2024)

Requirement Details Documentation Needed
Age Must be ≥18 years old Date of birth verification
Diagnosis Moderate to severe thyroid eye disease ICD-10 codes: H05.20, H05.21, E05.00, E05.01
Prescriber Ophthalmologist or endocrinologist involvement required Specialist consultation notes
Disease Severity Proptosis ≥3mm above normal OR moderate/severe soft tissue involvement OR diplopia OR orbital pain/pressure OR lid retraction ≥2mm Clinical measurements, photos, CAS score
Thyroid Status Euthyroid or mildly abnormal (FT4/FT3 <50% deviation from normal) Recent thyroid function tests
Exclusions No sight-threatening TED (severe optic neuropathy, corneal breakdown) Ophthalmologic examination notes
Dosing FDA-labeled regimen: 10mg/kg initial, then 20mg/kg every 3 weeks × 7 Weight-based dosing calculation

Essential Documents Checklist

Clinical Documentation:

  • Complete ophthalmology consultation with TED diagnosis
  • Endocrinology evaluation (if applicable)
  • Clinical Activity Score (CAS) assessment
  • Proptosis measurements in millimeters
  • Recent thyroid function tests (TSH, FT4, FT3)
  • Documentation of prior treatments attempted
  • High-quality orbital photographs showing disease severity

Administrative Documents:

  • Aetna prior authorization form for Tepezza
  • Patient demographics and insurance information
  • Prescriber NPI and DEA numbers
  • Planned infusion site details

Submit Your Prior Authorization Request

Finding the Right Forms

Aetna CVS Health requires specific prior authorization forms for Tepezza. Access current forms through:

  • Aetna provider portal (verify with current link)
  • CVS Caremark formulary navigator
  • Your prescriber's office (they should have current forms)
Tip: Forms change periodically. Always use the most current version dated within the last 12 months.

Submission Methods

Primary submission routes:

  1. Electronic: Through Aetna provider portal (fastest processing)
  2. Fax: Use the fax number specified on the PA form (typically 1-833-547-2030, but verify current number)
  3. Mail: Address provided on the current PA form

For CVS Specialty coordination:

  • If approved, CVS Specialty will contact you about logistics
  • They handle prior authorization follow-up and appeals support
  • Contact: 1-800-250-9631 for specialty pharmacy questions

Creating a Complete Request Packet

Cover letter should include:

  • Patient name and Aetna member ID
  • Clear statement: "Prior Authorization Request for Tepezza (teprotumumab, J3241)"
  • Prescriber contact information
  • Urgency level (standard or expedited)

Attach in this order:

  1. Completed PA form
  2. Prescriber's clinical summary letter
  3. Specialist consultation notes
  4. Laboratory results
  5. Orbital photographs (if available)
  6. Documentation of prior treatment failures

Follow-Up and Timeline Management

Expected Processing Times

  • Standard review: 7-14 business days
  • Expedited review: 72 hours (for urgent medical situations)
  • Additional information requests: May extend timeline by 7-10 days

Follow-Up Best Practices

Week 1: Call to confirm receipt

  • "I'm calling to confirm you received the prior authorization request for Tepezza submitted on [date]"
  • Request a reference number for tracking
  • Ask for the expected decision timeline

Week 2: Status check if no decision

  • "I'm following up on PA request #[reference number] for Tepezza"
  • Ask if additional information is needed
  • Request escalation to supervisor if approaching deadline
Sample script: "Hello, I'm calling about a prior authorization for Tepezza, reference number [X]. The patient has moderate thyroid eye disease and we submitted complete documentation on [date]. Can you provide a status update and expected decision date?"

If You Need to Provide Additional Information

Common Information Requests

Medical necessity clarifications:

  • More detailed clinical history
  • Additional specialist opinions
  • Specific contraindications to alternative treatments
  • Updated laboratory values

Administrative clarifications:

  • Corrected patient demographics
  • Updated prescriber information
  • Clarification of dosing regimen
  • Infusion site verification

How to Respond Quickly

  1. Same-day response: Fax additional information with a cover sheet referencing your original PA number
  2. Call to confirm receipt: Within 24 hours of sending additional information
  3. Document everything: Keep copies and note submission dates/times

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
"Not moderate/severe TED" Submit detailed CAS score, proptosis measurements, functional impact assessment Clinical photos, standardized assessments
"Thyroid not stable" Provide recent labs showing euthyroid/stable status TSH, FT4, FT3 within 30 days
"Prescriber not specialist" Add ophthalmology or endocrinology consultation Specialist referral and evaluation
"Experimental/investigational" Cite FDA approval, clinical guidelines FDA label, peer-reviewed studies
"Step therapy not met" Document contraindications or failures of steroids Treatment history, adverse events

First-Level Internal Appeal

Timeline: File within 60 days of denial notice Process:

  1. Complete Aetna appeal form (included with denial notice)
  2. Attach new supporting evidence
  3. Request peer-to-peer review with medical director
  4. Submit via method specified in denial letter

Peer-to-Peer Review Tips:

  • Schedule within 3 business days of request
  • Have clinical data readily available
  • Focus on FDA-approved indication and patient-specific factors
  • Reference Aetna's own medical policy criteria

Understanding Renewal Requirements

Important Limitations

Lifetime limit: Aetna typically covers only 8 infusions per lifetime for Tepezza. Retreatment requires exceptional circumstances and substantial new evidence.

No automatic renewal: Each course requires fresh prior authorization with updated clinical documentation.

Planning for Treatment Completion

  • Calendar the full 24-week course: Mark all 8 infusion dates
  • Monitor for side effects: Document any hearing changes, glucose elevations, or infusion reactions
  • Prepare outcome documentation: Measure proptosis improvement, quality of life changes
  • Consider maintenance planning: Discuss long-term TED management with your specialist

Appeals Process in Ohio

When patients and healthcare providers work with specialized support services like Counterforce Health, they can transform insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Internal Appeals with Aetna CVS Health

Standard Appeal Timeline:

  • File within: 180 days of denial
  • Decision timeframe: 30 days for non-urgent, 72 hours for urgent
  • How to file: Online portal, phone (member ID card number), or mail

Ohio External Review Process

If Aetna denies your internal appeal, Ohio residents can request an independent external review through the Ohio Department of Insurance.

Key Details:

  • Deadline: 180 days from final internal denial
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Cost: No fee to patient
  • Decision: Binding on Aetna if overturned

How to Request External Review:

  1. Submit written request to Aetna (they forward to Ohio DOI)
  2. Include all medical records and supporting documentation
  3. You have 10 business days to submit additional evidence after filing
  4. Independent medical experts review your case

Ohio Department of Insurance Contact:

From our advocates: We've seen Tepezza denials successfully overturned when patients provide comprehensive orbital measurements, clear documentation of moderate-to-severe disease, and evidence of stable thyroid function. The key is often demonstrating functional impairment beyond cosmetic concerns—diplopia affecting driving, work limitations due to orbital pain, or significant proptosis measurements compared to normal ranges for the patient's demographics.

Quick Reference Checklist

Before Submitting PA

  • Verify Aetna covers Tepezza under medical benefits
  • Confirm specialist involvement (ophthalmology/endocrinology)
  • Gather complete clinical documentation
  • Obtain current PA form
  • Document moderate-to-severe TED criteria

After Submission

  • Call within 3 days to confirm receipt
  • Track reference number
  • Follow up weekly if no decision
  • Respond quickly to information requests
  • Prepare for potential peer-to-peer review

If Denied

  • File internal appeal within 60 days
  • Request peer-to-peer review
  • Gather additional supporting evidence
  • Consider external review if internal appeal fails
  • Contact Ohio Department of Insurance if needed

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Tepezza in Ohio? A: Standard review typically takes 7-14 business days. Expedited review (for urgent situations) is completed within 72 hours. The timeline may extend if additional information is requested.

Q: What if Tepezza is not on my Aetna formulary? A: You can request a formulary exception by demonstrating medical necessity and providing clinical documentation. This follows the same prior authorization process with additional emphasis on why alternative treatments are inappropriate.

Q: Can I request an expedited appeal if denied? A: Yes, if a delay in treatment would seriously jeopardize your health or ability to regain maximum function. You'll need your doctor to document the urgent medical need.

Q: Does step therapy apply if I've tried treatments outside Ohio? A: Treatment history from other states should count toward step therapy requirements. Provide complete documentation of prior therapies, including dates, dosages, outcomes, and reasons for discontinuation.

Q: What happens if I move during treatment? A: Contact Aetna immediately to update your address and ensure continued coverage. Ohio residents moving out-of-state may face different coverage rules depending on their new location.

Q: How do I find a Tepezza-experienced provider in Ohio? A: Contact Amgen By Your Side for provider referrals, or ask your current ophthalmologist for referrals to TED specialists in Ohio.

Q: What if my employer plan is self-funded? A: Self-funded ERISA plans may follow different appeal procedures than state-regulated plans. However, many voluntarily use external review processes. Contact your HR department for specific appeal rights under your plan.

Q: Can I use manufacturer copay assistance with Aetna? A: Copay assistance availability depends on your specific plan type. Commercial plans often allow manufacturer support, while government plans (Medicare, Medicaid) typically prohibit it. Contact CVS Specialty at 1-800-250-9631 for guidance.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeal processes. It is not medical advice or legal counsel. Coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider about treatment decisions and verify current coverage details with your insurance company. For personalized assistance with complex coverage challenges, organizations like Counterforce Health specialize in helping patients and providers navigate insurance approval processes for specialty medications.

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