By Counterforce Health Team in Tepezza (teprotumumab) —

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

Quick Answer: Aetna CVS Health covers Tepezza for moderate-to-severe thyroid eye disease in Virginia with mandatory prior authorization requiring ophthalmologist evaluation, Clinical Activity Score ≥4, and documented steroid failure. Submit PA through CVS Specialty Pharmacy coordination. If denied, Virginia's Bureau of Insurance offers external review within 120 days with 45-day decisions and 73% overturn rates for specialty drug appeals. Start with your ophthalmologist gathering documentation today.

Table of Contents

  1. When Tepezza Alternatives Make Sense
  2. Typical TED Treatment Alternatives
  3. Pros and Cons Overview
  4. Exception Strategy for Tepezza
  5. Switching Logistics and Coordination
  6. Re-trying for Tepezza Later
  7. Virginia Appeals Process
  8. FAQ

When Tepezza Alternatives Make Sense

If Aetna CVS Health initially denies Tepezza (teprotumumab) for your thyroid eye disease (TED), you're not out of options. Sometimes starting with alternative treatments can actually strengthen your case for eventual Tepezza approval—and for some patients, these alternatives provide meaningful relief without the $350,000+ cost of a full Tepezza course.

Aetna typically requires step therapy, meaning you'll need to try and document failure of less expensive treatments first. According to Aetna's clinical policy, this usually includes:

  • Systemic corticosteroids (typically 12-week trial with ≤8g cumulative dose)
  • Selenium supplementation (for mild TED in selenium-deficient areas)
  • Conservative management (lubricants, prism glasses, protective eyewear)

The good news? Virginia's external review process has overturned approximately 50-60% of specialty drug denials when proper documentation is provided, according to data from similar state programs.

From our advocates: We've seen patients who were initially denied Tepezza get approved after a 3-month trial of alternative treatments that was thoroughly documented. The key was having the ophthalmologist photograph progression and measure proptosis at each visit, creating an undeniable paper trail of inadequate response.

Typical TED Treatment Alternatives

First-Line Treatments (Usually Required by Aetna)

Intravenous Methylprednisolone (IVMP)

  • Standard protocol: 500mg weekly for 6 weeks, then 250mg weekly for 6 weeks
  • Combined with mycophenolate mofetil (MMF) shows up to 91% response at 24 weeks
  • Covered under medical benefit; requires infusion center coordination

Oral Corticosteroids

  • Prednisone 80-100mg daily, tapered over 12-16 weeks
  • Less effective than IV but easier to administer
  • Watch for diabetes, bone loss, psychiatric effects

Selenium Supplementation

  • 100 μg twice daily for 6 months minimum
  • Most effective for mild TED in selenium-deficient regions
  • Available over-the-counter; document trial in medical records

Second-Line Options (After Steroid Failure)

Orbital Radiotherapy

  • 20 Gy total dose (2 Gy over 10 days)
  • Particularly effective for diplopia and dysthyroid optic neuropathy
  • Contraindicated under age 35 or with diabetic/hypertensive retinopathy
  • Reduces optic neuropathy risk to 0% when combined with steroids

Rituximab (Off-Label)

  • B-cell depleting monoclonal antibody
  • Used for steroid-resistant cases
  • Requires prior authorization as specialty medication

Tocilizumab (Off-Label)

  • IL-6 receptor antagonist
  • Emerging evidence for TED treatment
  • Significantly more expensive than steroids but less than Tepezza

Pros and Cons Overview

Treatment Pros Cons Aetna Coverage
IV Steroids + MMF 91% response rate, covered, builds Tepezza case Side effects, monitoring needed ✓ Standard coverage
Oral Steroids Easy administration, covered Lower efficacy, systemic effects ✓ Standard coverage
Selenium Safe, inexpensive, OTC Limited efficacy, mild TED only ✓ No PA required
Orbital Radiation Effective for diplopia/neuropathy Age restrictions, specialist required ✓ With authorization
Rituximab Alternative for failures Off-label, expensive, side effects PA required
Tocilizumab Promising results Limited data, very expensive PA required

Key Access Considerations

Testing Requirements: Before starting any treatment, ensure thyroid function is normalized. Aetna requires documentation of euthyroid status within 2 months of treatment initiation.

Monitoring Needs:

  • Steroids: Blood sugar, bone density, psychiatric screening
  • Biologics: CBC, hepatitis screening, tuberculosis testing
  • All treatments: Serial photography, proptosis measurements, Clinical Activity Score

Specialist Coordination: Virginia ophthalmologists experienced with TED can streamline the process. Consider academic centers like UVA Health where providers understand Aetna's requirements.

Exception Strategy for Tepezza

Even if alternatives are tried first, you can request a formulary exception for Tepezza if you meet specific criteria. Here's when to request an exception:

Immediate Exception Scenarios

  • Sight-threatening complications (dysthyroid optic neuropathy, severe exposure keratopathy)
  • Documented contraindications to all step-therapy alternatives
  • Previous failure of adequate steroid trials with clear documentation
  • Rapid progression despite maximum conservative treatment

Evidence That Strengthens Appeals

Clinical Documentation Package:

  • Serial photographs showing progression
  • Proptosis measurements (normal: <20mm; moderate TED: 20-23mm; severe: >23mm)
  • Clinical Activity Score (CAS) ≥4 out of 7 points
  • Functional impact assessment (diplopia, vision loss, quality of life scores)

Treatment History:

  • Detailed records of prior therapies, doses, duration
  • Specific reasons for discontinuation (side effects, inadequate response)
  • Timeline showing progression despite treatment

Specialist Letters:

  • Ophthalmologist attestation of medical necessity
  • Endocrinologist confirmation of optimized thyroid management
  • Peer-reviewed literature supporting off-label use if applicable
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing your specific denial reason and crafting point-by-point rebuttals using payer-specific criteria.

Switching Logistics and Coordination

Provider Coordination Steps

  1. Ophthalmology Assessment (1-2 weeks)
    • Complete TED evaluation with CAS scoring
    • Baseline photography and proptosis measurements
    • Treatment plan documentation
  2. Endocrinology Consultation (1-2 weeks)
    • Optimize thyroid function
    • Screen for contraindications
    • Coordinate timing with ophthalmologist
  3. Prior Authorization Submission (3-5 business days)
    • Submit through CVS Caremark portal
    • Include all required documentation
    • Specify J-code J3241 for proper billing

CVS Specialty Pharmacy Coordination

Contact Information:

  • Phone: 1-800-237-2767
  • Fax for PA: 1-888-267-3277
  • Provider portal: CVS Caremark Specialty

Required Information:

  • Complete diagnosis (ICD-10: H05.20 for unspecified TED)
  • Weight-based dosing calculation
  • Infusion site preference and scheduling
  • Insurance verification and benefits

Timeline Expectations

Step Standard Timeline Expedited (if applicable)
PA Review 15-30 business days 72 hours
Specialty Pharmacy Setup 3-5 business days 24 hours
First Infusion Scheduling 1-2 weeks 3-5 days
Appeals Decision 30-45 days 72 hours

Re-trying for Tepezza Later

If you start with alternatives but they prove inadequate, document everything for a stronger Tepezza appeal:

Critical Documentation During Alternative Trials

Monthly Progress Notes:

  • CAS scores with standardized photos
  • Proptosis measurements (same examiner, same technique)
  • Functional assessments (diplopia severity, vision changes)
  • Side effects and tolerability issues

Objective Measurements:

  • Visual acuity and visual fields
  • Extraocular muscle function
  • Lid position and closure
  • Corneal health and tear film

Quality of Life Impact:

  • Standardized questionnaires (GO-QOL if available)
  • Work/daily activity limitations
  • Psychological impact documentation

When to Resubmit for Tepezza

Clear Progression Criteria:

  • Worsening CAS despite 12+ weeks of adequate alternative therapy
  • New-onset diplopia or vision threats
  • Functional deterioration affecting daily activities
  • Intolerable side effects from alternatives

Resubmission Strategy:

  • Include side-by-side photo comparisons
  • Highlight specific CAS component worsening
  • Emphasize time-sensitive nature of TED treatment window
  • Reference FDA labeling supporting treatment regardless of disease activity or duration

Virginia Appeals Process

If Aetna denies your Tepezza request, Virginia offers robust external review rights through the State Corporation Commission's Bureau of Insurance.

Internal Appeals First

Timeline: Must file within 180 days of denial Contact: 1-855-582-2025 (standard) or 1-800-408-2386 (urgent) Documents: Original denial letter, additional clinical evidence, peer-to-peer request

Virginia External Review Process

Eligibility: After completing internal appeals, you have 120 days to file Contact: Virginia Bureau of Insurance Life & Health Consumer Services Phone: 1-877-310-6560 Forms: Form 216-A (External Review Request) available on SCC website

Process Timeline:

  • Standard Review: 45-day decision by Independent Review Organization
  • Expedited Review: 72 hours for urgent medical necessity; 6 business days for experimental treatment denials
  • Success Rate: Approximately 50-60% overturn rate for specialty drug denials

Key Advantages in Virginia:

  • No cost to consumers for external review
  • Board-certified physician reviewers with relevant expertise
  • Binding decisions on insurers (must comply within 24 hours if overturned)
  • Special provisions for cancer treatment (can bypass internal appeals)
Note: Virginia's Managed Care Ombudsman can provide additional support for HMO and managed care plan issues at the same 1-877-310-6560 number.

When to Escalate Further

If external review fails, consider:

  • Legal consultation for potential ERISA violations (self-funded plans)
  • State insurance complaint for procedural violations
  • Federal external review (if employer plan opts out of Virginia process)

FAQ

How long does Aetna CVS Health prior authorization take in Virginia? Standard PA decisions take 15-30 business days. Expedited reviews for urgent cases are completed within 72 hours. Submit through CVS Caremark Specialty Pharmacy for fastest processing.

What if Tepezza is non-formulary on my Aetna plan? You can request a formulary exception through the process outlined in your Evidence of Coverage. Contact 1-855-582-2025 to initiate the exception request with supporting clinical documentation.

Can I request an expedited appeal if my TED is worsening? Yes, if your ophthalmologist certifies that waiting for standard review could seriously jeopardize your vision or health. Virginia provides expedited external review within 72 hours for urgent medical necessity denials.

Does step therapy apply if I've tried alternatives outside Virginia? Yes, if you have documented evidence of adequate trials and failures with required step-therapy medications, this should satisfy Aetna's requirements regardless of where treatment occurred.

What's the difference between medical necessity and experimental denials? Medical necessity denials question whether treatment is appropriate for your condition. Experimental denials claim the treatment lacks sufficient evidence. Different appeal strategies apply—medical necessity focuses on clinical criteria, while experimental denials require literature reviews and guideline citations.

How much will I pay out-of-pocket for Tepezza with Aetna? Tepezza is covered under the medical benefit, so coinsurance applies rather than flat copays. With a typical 20% coinsurance, expect $70,000-$100,000+ out-of-pocket for a full course. Check Amgen's patient assistance programs for potential cost support.

Can I get a second opinion to strengthen my appeal? Absolutely. Getting an independent ophthalmologist's assessment, particularly from an academic medical center experienced with TED, can provide valuable additional documentation for appeals.

What happens if I need a second course of Tepezza later? Aetna's policy currently limits coverage to one lifetime course of 8 infusions. Any future treatment would require extensive documentation of disease reactivation and likely involve external review or experimental treatment pathways.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For personalized assistance with prior authorization and appeals, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

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