By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Aetna CVS Health in Washington: Prior Authorization Forms, Appeal Process & Success Strategies

Answer Box: Getting Tepezza Covered by Aetna CVS Health in Washington

Fastest path to approval: Your ophthalmologist submits Aetna's Tepezza Precertification Form with documented moderate-to-severe TED diagnosis and evidence of failed step therapy (prednisone, methimazole). If denied, file internal appeals within 180 days, then request external review through Washington's Independent Review Organization. Start today: Contact your eye doctor to begin the precertification process and gather records of previous treatments.

Table of Contents

Plan Types & Coverage Implications

Your Aetna CVS Health plan type in Washington affects how you access Tepezza:

HMO Plans:

  • Requires referral from your primary care physician to an ophthalmologist
  • Coverage limited to in-network providers only
  • May need PCP coordination for specialty medication approvals

PPO Plans:

  • No referral required—you can see an ophthalmologist directly
  • Out-of-network options available (higher cost-sharing)
  • More flexibility in provider choice

EPO Plans:

  • In-network only, but no referral requirements
  • Direct access to specialists within the network
  • Balance of HMO cost control with PPO convenience
Note: All plan types require prior authorization for Tepezza regardless of network restrictions. Verify your specific plan details through Aetna's member portal.

Formulary Status & Tier Placement

Tepezza is classified as a specialty medication on Aetna CVS Health formularies, typically placed on the highest specialty tier. This means:

  • Higher cost-sharing than standard medications
  • Mandatory use of CVS Specialty Pharmacy for fulfillment
  • Strict prior authorization requirements
  • Limited to FDA-approved indication (thyroid eye disease)

Alternative agents that may be required first include:

  • Prednisone (oral corticosteroid)
  • IV methylprednisolone
  • Methimazole or propylthiouracil (antithyroid drugs)
  • Conservative measures (eye drops, compresses, prisms)

Prior Authorization & Step Therapy Requirements

Aetna requires step therapy before approving Tepezza. According to their clinical policy, patients must have:

Required Prior Treatments:

  1. Conservative measures:
    • Head elevation during sleep
    • Cool compresses
    • Lubricating eye drops
    • Sunglasses for light sensitivity
    • Prism glasses for double vision
  2. Medications tried and failed/not tolerated:
    • Diuretics
    • Methimazole or propylthiouracil
    • Prednisone or other glucocorticoids

Clinical Criteria:

  • Age 18 or older
  • Moderate-to-severe thyroid eye disease
  • Consultation with or prescription by an ophthalmologist
  • One-time course only (8 infusions maximum)

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies like Aetna's step therapy requirements and crafting evidence-backed rebuttals that address each denial reason systematically.

Specialty Pharmacy Process

Once approved, Tepezza must be dispensed through CVS Specialty Pharmacy:

Enrollment Steps:

  1. Your doctor submits the approved prescription to CVS Specialty
  2. CVS contacts you to complete enrollment and insurance verification
  3. Infusion appointments scheduled at approved facility
  4. 8 infusions administered every 3 weeks (first dose 10mg/kg, subsequent doses 20mg/kg)

Timeline:

  • Approval process: Up to 90 days
  • First infusion scheduling: 7-14 days after approval
  • Complete treatment course: Approximately 5 months
Tip: Enroll in Amgen By Your Side patient support program to help navigate the specialty pharmacy process and provide insurance advocacy.

Cost-Share Considerations

Tepezza costs approximately $350,000-$500,000 for a full course. Your out-of-pocket costs depend on:

  • Specialty tier copay/coinsurance (varies by plan)
  • Annual out-of-pocket maximum (provides cost protection)
  • Deductible requirements (if applicable to specialty drugs)

Cost Assistance Options:

  • Amgen copay assistance program
  • Patient foundation grants
  • Hospital financial assistance programs
  • Washington state pharmaceutical assistance programs

This information is educational only and not financial advice. Consult your plan documents for specific cost-sharing details.

Submission Process & Required Forms

Step-by-Step Submission:

1. Complete Aetna Tepezza Precertification Form

  • Download from Aetna's website
  • All fields must be completed by prescribing physician
  • Include patient demographics, insurance details, diagnosis codes

2. Gather Supporting Documentation

  • Medical records showing TED diagnosis and severity
  • Photos documenting eye changes
  • Clinical Activity Score (CAS) measurements
  • Records of failed prior treatments
  • Ophthalmology consultation notes

3. Submit via Fax or Phone

  • Fax: 1-888-267-3277
  • Phone: 1-866-752-7021
  • Allow 2-3 business days for receipt confirmation

4. Track Status

  • Standard review: 15-30 days
  • Expedited review: 72 hours (if urgent medical need)
  • Contact Aetna member services for status updates

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient step therapy Document failed/intolerated treatments Medication trial records, side effect notes
Not moderate-to-severe TED Provide detailed severity assessment CAS scores, proptosis measurements, photos
Missing ophthalmology consult Obtain specialist evaluation Ophthalmologist's letter and examination notes
Incomplete medical records Submit comprehensive documentation Complete chart notes, lab results, imaging
Experimental/investigational Emphasize FDA approval FDA labeling, clinical guidelines

Appeals Process in Washington

If your Tepezza request is denied, Washington provides strong consumer protections:

Internal Appeals (Aetna):

Level 1 Appeal:

  • File within 180 days of denial
  • Submit via member portal, mail, or phone
  • Include denial letter and additional supporting evidence
  • Decision timeline: 30 days (standard), 72 hours (expedited)

Level 2 Appeal:

  • Available if Level 1 is denied
  • Same submission methods and timelines
  • Consider requesting peer-to-peer review with medical director

External Review (Washington State):

After exhausting internal appeals, you can request Independent Review Organization (IRO) review:

  • File within 4 months of final internal denial
  • Contact Washington Office of Insurance Commissioner: 1-800-562-6900
  • IRO review is free to patients
  • Decision timeline: 30 days (standard), 72 hours (expedited)
  • Success rate: Approximately 40-45% of specialty drug appeals are overturned
From our advocates: We've seen patients successfully overturn Tepezza denials by submitting comprehensive medical necessity letters that directly address Aetna's specific policy criteria, particularly emphasizing the moderate-to-severe TED diagnosis with objective measurements and photographic evidence. The key is matching your clinical documentation to their published requirements.

When Counterforce Health reviews a Tepezza denial, we analyze Aetna's exact policy language and craft point-by-point rebuttals that address each denial basis with the right clinical evidence and regulatory citations.

When to Escalate

Contact Washington regulators if you experience:

  • Unreasonable delays in processing
  • Repeated requests for the same documentation
  • Denial of expedited review for urgent cases
  • Failure to follow proper appeal procedures

Washington Office of Insurance Commissioner:

  • Consumer hotline: 1-800-562-6900
  • Website: insurance.wa.gov
  • File complaints online or by phone

FAQ

Q: How long does Aetna prior authorization take for Tepezza in Washington? A: Standard review takes 15-30 days. Expedited review (for urgent medical need) is completed within 72 hours.

Q: What if Tepezza is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Non-formulary doesn't mean automatic denial if medically necessary.

Q: Can I get Tepezza covered if I haven't tried all step therapy requirements? A: Exceptions may be granted if other treatments are contraindicated, previously failed, or would cause significant delay in necessary treatment.

Q: Does step therapy apply if I tried treatments in another state? A: Yes, documented treatment failures from any location count toward step therapy requirements if properly documented.

Q: What happens if my appeal is denied by the IRO? A: IRO decisions are binding on the insurer. If overturned in your favor, Aetna must provide coverage. If upheld, you may consider legal consultation.

Q: Can I continue current eye treatments while appealing? A: Yes, continue all current treatments as prescribed. Don't stop existing therapies during the appeals process.

Q: How do I request an expedited appeal? A: Your physician must certify that waiting for standard review could seriously jeopardize your health. Submit urgency documentation with your appeal.

Q: What if I can't afford the copay even with insurance? A: Explore Amgen's patient assistance program, hospital charity care, and pharmaceutical assistance foundations for additional support.

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all plans Aetna Policy
Age Limit 18 years or older Aetna Clinical Policy
Diagnosis Moderate-to-severe TED FDA Labeling
Prescriber Ophthalmologist required Aetna Precert Form
Step Therapy Conservative measures + medications Aetna Policy
Treatment Limit One course (8 infusions) maximum Clinical Guidelines
Appeal Deadline 180 days (internal), 4 months (external) Washington State Law

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by plan and change over time. Always consult your specific plan documents and healthcare providers for personalized guidance. For assistance with complex appeals, consider consulting with insurance advocacy services like Counterforce Health, which specializes in turning denials into successful approvals through evidence-based appeals.

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