By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Blue Cross Blue Shield in Georgia: Complete Requirements Checklist

Answer Box: Getting Tepezza Covered by Blue Cross Blue Shield Georgia

Blue Cross Blue Shield Georgia (Anthem BCBS) requires prior authorization for Tepezza (teprotumumab) for thyroid eye disease. Key requirements: active TED diagnosis, age 18+, ophthalmology/endocrinology specialist prescriber, and monitoring agreements. The fastest path: submit complete PA with clinical documentation through your provider's portal, use CVS Specialty for medical benefit drugs, and prepare for 8-infusion lifetime limit. Start by verifying your provider is in-network and gathering prior therapy records today.

First step: Contact your eye doctor or endocrinologist to initiate prior authorization and confirm they're contracted with BCBS Georgia.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: Tracking Your Request
  9. Common Denial Reasons & How to Avoid Them
  10. Appeals Process in Georgia
  11. Quick Reference Checklist
  12. FAQ

Who Should Use This Checklist

This guide is for Georgia residents with Blue Cross Blue Shield coverage (Anthem BCBS Georgia) who need Tepezza for thyroid eye disease. You'll find this most helpful if you:

  • Have been diagnosed with TED by an ophthalmologist or endocrinologist
  • Are considering Tepezza treatment or received a denial
  • Need to understand BCBS Georgia's specific requirements
  • Want to maximize your chances of approval on the first submission

Expected outcome: With complete documentation meeting all criteria, most medically appropriate Tepezza requests are approved. However, BCBS Georgia has strict lifetime limits (one 8-infusion course per member) and requires ongoing monitoring agreements.

Member & Plan Basics

Coverage Verification Checklist

Before starting your prior authorization, confirm these basics:

✓ Active BCBS Georgia Coverage

  • Your member ID should show "Anthem" or "BCBS Georgia"
  • Verify coverage is active through the member portal or by calling the number on your card

✓ Plan Type & Benefits

  • Tepezza is covered under your medical benefit (not pharmacy benefit)
  • Most BCBS Georgia plans require prior authorization for specialty biologics
  • Check if you have a deductible that applies to infused medications

✓ Provider Network Status

  • Your prescribing specialist must be in-network with BCBS Georgia
  • The infusion center must also be contracted with your plan
  • Verify both before starting the PA process
Tip: Call BCBS Georgia member services at the number on your card to verify both provider and facility network status before your first appointment.

Clinical Criteria Requirements

BCBS Georgia follows specific medical criteria for Tepezza coverage. Your provider must document all of the following:

Core Requirements

Requirement Details Documentation Needed
Diagnosis Active thyroid eye disease (TED) ICD-10 codes H05.20-H05.22
Age 18 years or older Date of birth verification
Specialist Care Ophthalmology or endocrinology prescriber Provider credentials/specialty
Monitoring Agreement Provider commits to monitor infusion reactions and blood glucose Signed attestation
Contraception Counseling For women of reproductive age Documentation of counseling

Clinical Documentation Requirements

Your specialist must provide detailed records showing:

  • TED severity: Clinical Assessment Score (CAS), proptosis measurements, functional impact
  • Prior treatments tried: Steroids, other immunosuppressants, or documentation why these are contraindicated
  • Thyroid status: Recent thyroid function tests (TSH, Free T4, Free T3)
  • Treatment goals: Specific outcomes expected from Tepezza therapy
Note: BCBS Georgia requires "active" TED in their criteria, but FDA labeling covers TED regardless of activity. If you have inactive TED, your provider should reference the FDA indication and provide medical justification.

Coding & Billing Requirements

Proper coding is crucial for Tepezza approval and payment:

HCPCS Coding

  • Primary code: J3241 (teprotumumab-trbw, 10 mg per unit)
  • Dosing calculation: Total mg administered ÷ 10 = billable units
  • Wastage modifiers: JW (wasted drug), JZ (no waste) - required for accurate billing

ICD-10 Diagnosis Codes

  • H05.20: Unspecified exophthalmos
  • H05.21: Displacement of globe, right/left eye
  • H05.22: Edema of orbit, right/left eye
  • Link diagnosis codes to each claim line

Administration Details

  • Initial dose: 10 mg/kg IV infusion
  • Subsequent doses: 20 mg/kg IV every 3 weeks (7 additional infusions)
  • Total course: 8 infusions over approximately 21 weeks

Documentation Packet

Your provider needs to submit a comprehensive packet including:

Medical Necessity Letter Components

Patient Information

  • Full name, date of birth, BCBS Georgia member ID
  • Primary and secondary insurance information

Clinical Narrative

  • TED diagnosis with onset date and progression
  • Current symptoms and functional limitations
  • Prior treatments attempted and outcomes
  • Why Tepezza is medically necessary for this patient
  • Planned dosing schedule and monitoring plan

Supporting Attachments

  • Recent ophthalmology exam notes
  • Thyroid function tests (within 6 months)
  • Photos documenting proptosis or lid retraction
  • Any relevant imaging (CT/MRI orbits)
  • Prior therapy documentation (prescriptions, progress notes)

Letter Template Resources

Amgen provides a downloadable Letter of Medical Necessity template with customizable fields for all required information.

Submission Process

Correct Form and Portal

For Providers:

  • Submit through Anthem's provider portal or designated PA system
  • Use the most current PA form (verify version date)
  • Include all required fields - incomplete forms cause automatic delays

Required Information That Commonly Causes Rejections:

  • Missing provider NPI number
  • Incorrect member ID format
  • Unsigned attestations
  • Missing diagnosis codes
  • Incomplete dosing calculations

Submission Timeline

  • Allow 5-10 business days for standard PA review
  • Expedited reviews available for urgent medical situations
  • Submit renewal requests 30 days before current authorization expires
Important: BCBS Georgia allows only one lifetime approval for Tepezza (8 infusions maximum). Plan your timing carefully.

Specialty Pharmacy Requirements

BCBS Georgia requires specific specialty pharmacy vendors for coverage:

Approved Specialty Pharmacies

For Medical Benefit (Provider-Administered):

  • CVS Specialty (primary preferred vendor)
  • Verify current network status before ordering

Alternative In-Network Options:

  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy
  • Medical Park 11 Pharmacy
  • PharmaScript
  • Piedmont Direct Pharmacy

Important Notes

  • Coverage only guaranteed with in-network specialty pharmacies
  • Out-of-network pharmacies may result in full patient financial responsibility
  • Your infusion center will coordinate with the specialty pharmacy
  • Verify pharmacy network status before each order

After Submission: Tracking Your Request

What to Record

  • Confirmation number from PA submission
  • Date submitted and review timeline provided
  • Contact information for follow-up
  • Reference number for all communications

Status Check Schedule

  • Day 3: Confirm receipt of PA request
  • Day 7: Check for any additional information requests
  • Day 10: Follow up if no determination received
  • If denied: Request denial letter with specific reasons

Next Steps After Approval

  • Coordinate with specialty pharmacy for drug ordering
  • Schedule infusion appointments
  • Confirm infusion site has received authorization
  • Verify patient responsibility/copay amounts

Common Denial Reasons & How to Avoid Them

Denial Reason How to Prevent Documentation Fix
Insufficient clinical documentation Submit complete exam notes, photos, measurements Detailed ophthalmology records with CAS scores
Prior therapy not documented List all previous treatments with dates and outcomes Prescription records, progress notes showing failures
Non-network provider Verify provider contracts before starting Use only BCBS Georgia contracted specialists
Incorrect coding Double-check J3241 units calculation Weight-based dosing worksheet with calculations
Missing monitoring agreements Include signed provider attestations Completed monitoring commitment forms

Five Critical Pitfalls to Avoid

  1. Submitting without specialist involvement - Only ophthalmologists or endocrinologists can prescribe
  2. Incomplete prior therapy documentation - Show what was tried and why it failed
  3. Missing thyroid status - Include recent TSH, Free T4, Free T3 results
  4. Incorrect pharmacy routing - Use only approved specialty pharmacy vendors
  5. Timing errors - Remember the lifetime limit - you only get one chance for approval

Appeals Process in Georgia

If your Tepezza request is denied, Georgia provides a structured appeals process:

Internal Appeal (First Level)

  • Timeline: File within 180 days of denial
  • Process: Submit through BCBS Georgia's appeal process
  • Documentation: Include denial letter, additional clinical support, peer-reviewed studies

External Review (Second Level)

  • Timeline: Request within 60 days of final internal denial
  • Authority: Georgia Department of Insurance
  • Contact: Administrative Procedure Division at [email protected]
  • Cost: Nominal fee (≤$25, refundable if successful)
  • Decision timeline: 45 days for standard review, 72 hours for expedited

Expedited Appeals

Available when delays would:

  • Seriously jeopardize your health
  • Compromise your ability to regain function
  • Subject you to severe pain

For urgent appeals: Include provider certification of medical urgency with your request.

Georgia-Specific Rights: External review decisions are binding on BCBS Georgia. The state requires independent medical review by specialists in the same field.

Quick Reference Checklist

Before Starting:

  • Verify BCBS Georgia coverage is active
  • Confirm provider is in-network ophthalmologist or endocrinologist
  • Check infusion center network status
  • Gather prior therapy records

Clinical Requirements:

  • TED diagnosis confirmed by specialist
  • Age 18 or older
  • Recent thyroid function tests
  • Prior treatments documented (or contraindications explained)
  • Provider monitoring agreements signed

Documentation Packet:

  • Complete medical necessity letter
  • Clinical exam notes with CAS scores
  • Proptosis measurements and photos
  • Laboratory results (thyroid function)
  • Prior therapy documentation

Submission:

  • Use current PA form version
  • Submit through correct portal/process
  • Include all required provider information
  • Verify specialty pharmacy is in-network
  • Keep confirmation numbers and tracking information

FAQ

How long does BCBS Georgia PA take for Tepezza? Standard prior authorization review takes 5-10 business days. Expedited reviews for urgent medical situations can be completed in 24-72 hours.

What if Tepezza is non-formulary on my plan? Tepezza requires prior authorization on most BCBS Georgia plans but is generally covered when criteria are met. Non-formulary status doesn't prevent coverage with appropriate medical justification.

Can I request an expedited appeal in Georgia? Yes. Georgia allows expedited internal and external appeals when delays would jeopardize your health. Include provider certification of urgency with your request.

Does step therapy apply if I failed treatments outside Georgia? Prior therapy documentation from any state is acceptable. Include prescription records and clinical notes showing treatment failures or intolerances.

What's the lifetime limit for Tepezza with BCBS Georgia? BCBS Georgia approves only one complete course (8 infusions) per member's lifetime. Additional infusions require exceptional medical justification and are rarely approved.

Who can prescribe Tepezza in Georgia? Only ophthalmologists or endocrinologists can prescribe Tepezza. Primary care physicians cannot obtain prior authorization approval for this medication.

What if my infusion center isn't in-network? Out-of-network facilities may not be covered, even with prior authorization. Verify facility network status or request a network exception before starting treatment.

Can I appeal directly to Georgia insurance regulators? You must complete BCBS Georgia's internal appeal process first. External review through the Georgia Department of Insurance is available after internal appeals are exhausted.

For complex cases or challenging denials, Counterforce Health helps patients and providers turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to each payer's specific requirements, potentially saving months of back-and-forth with insurance companies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider about treatment options and verify current requirements with BCBS Georgia. For assistance with insurance appeals or coverage issues, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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