By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Blue Cross Blue Shield in North Carolina: Complete Guide to Prior Authorization and Appeals

Answer Box: Getting Tepezza Covered by BCBS in North Carolina

Tepezza (teprotumumab) requires prior authorization from Blue Cross Blue Shield of North Carolina for thyroid eye disease coverage. Your fastest path to approval: 1) Gather comprehensive TED documentation including Clinical Activity Score (CAS ≥3), proptosis measurements, and prior therapy failures; 2) Have your ophthalmologist or endocrinologist submit the PA request through BCBS's provider portal with complete medical records; 3) If denied, file an internal appeal within 180 days, then request external review through North Carolina's Smart NC program within 120 days. Start by downloading BCBS NC's Part B Prior Authorization Criteria and contacting your provider today.

Table of Contents

  1. Understanding BCBS Coverage for Tepezza
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process in North Carolina
  6. Smart NC External Review
  7. Cost and Financial Assistance
  8. Templates and Scripts
  9. When to Escalate
  10. FAQ

Understanding BCBS Coverage for Tepezza

Blue Cross Blue Shield of North Carolina covers Tepezza (teprotumumab) as a medical benefit under Part B for patients with thyroid eye disease (TED). The drug requires prior authorization regardless of your specific BCBS plan type.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all BCBS NC plans BCBS NC Provider Portal
Formulary Status Medical benefit, not pharmacy BCBS NC drug formulary
Billing Code J3241 (10 mg units) Tepezza Billing Guide
Site of Care In-network infusion center or hospital outpatient Provider network directory
Appeal Deadline 180 days (internal), 120 days (external) BCBS NC member handbook

Tepezza carries a significant cost—often $350,000-$500,000+ for the full 8-infusion course—making thorough documentation essential for approval.

Prior Authorization Requirements

BCBS North Carolina requires comprehensive clinical documentation to approve Tepezza coverage. Here's what your provider needs to submit:

Essential Documentation Checklist

Clinical Requirements:

  • Confirmed diagnosis of thyroid eye disease with appropriate ICD-10 codes
  • Clinical Activity Score (CAS) ≥3 out of 7 at baseline
  • Quantified proptosis measurements using Hertel exophthalmometer
  • Evidence of moderate-to-severe TED symptoms
  • Current thyroid function tests showing euthyroid status
  • Documentation of prior therapy failures or contraindications

Provider Requirements:

  • Prescription from ophthalmologist, endocrinologist, or oculoplastic surgeon
  • Detailed medical necessity letter
  • Treatment plan for 8 infusions over 21 weeks
  • Patient monitoring protocol
Clinician Corner: Your medical necessity letter should address each BCBS criterion specifically. Include the patient's CAS score, exact proptosis measurements in millimeters, detailed history of prior treatments (corticosteroids, immunosuppressants), and why Tepezza is the appropriate next step. Reference FDA approval for TED regardless of disease activity or duration.

Clinical Activity Score Documentation

The CAS is crucial for approval. Document these 7 baseline symptoms (1 point each):

  • Spontaneous retrobulbar pain
  • Pain on eye movement
  • Eyelid redness
  • Conjunctival redness
  • Eyelid swelling
  • Inflammation of caruncle/plica
  • Conjunctival edema (chemosis)

Active TED typically requires CAS ≥3. For follow-up assessments, include additional measurements like proptosis changes ≥2mm and decreased eye movements.

Step-by-Step: Fastest Path to Approval

Step 1: Gather Complete Documentation (Patient + Clinic)

Timeline: 1-2 weeks
Who: Patient gathers insurance info; clinic compiles medical records
Documents needed: Insurance card, prior therapy records, recent labs, CAS assessment, proptosis measurements

Step 2: Provider Submits Prior Authorization (Clinic)

Timeline: Submit within 1 business day of gathering docs
How: Through BCBS NC provider portal or designated fax
Include: Complete PA form, medical necessity letter, supporting clinical notes, lab results

Step 3: BCBS Review Process (BCBS)

Timeline: 5-14 business days for standard review
Process: Medical director reviews against published criteria
Expedited option: Available for urgent cases (72-hour turnaround)

Step 4: Receive Determination (All parties)

Approval: Authorization letter with number of approved infusions
Denial: Detailed explanation of denial reasons and appeal rights

Step 5: Begin Treatment or Appeal (Patient + Clinic)

If approved: Schedule infusions at in-network facility
If denied: Proceed to internal appeal process immediately

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Not moderate-to-severe TED" Submit detailed CAS scores, photos, quality of life impact CAS assessment, clinical photos, patient questionnaire
"No prior therapy failures" Document steroid trials, contraindications, or intolerance Treatment timeline, adverse event reports, specialist notes
"Prescriber not qualified" Confirm specialist credentials Provider CV, board certifications
"Not euthyroid" Submit current thyroid function tests Recent TSH, free T4, free T3 labs
"Experimental/investigational" Reference FDA approval for TED FDA label, clinical guidelines
From our advocates: "We've seen denials overturned when providers include side-by-side photos showing TED progression and a detailed timeline of failed treatments. One case was approved after the specialist included a letter explaining why the patient couldn't tolerate steroids due to diabetes complications—specificity matters."

Appeals Process in North Carolina

North Carolina offers robust appeal rights through a two-level internal process followed by external review through Smart NC.

Internal Appeals (Level 1 & 2)

Timeline: Must file within 180 days of denial
Process: Submit appeal letter with new evidence to BCBS
Turnaround: 30 days for standard, 72 hours for expedited
Success tip: Address each specific denial reason with new clinical evidence

Peer-to-Peer Review

Before formal appeals, request a peer-to-peer review where your specialist speaks directly with BCBS's medical director. This often resolves coverage disputes quickly.

Script for requesting P2P: "I'm calling to request a peer-to-peer review for my patient's Tepezza prior authorization denial. The denial cited [specific reason], but I have additional clinical information that demonstrates medical necessity."

Smart NC External Review

If BCBS denies your internal appeals, North Carolina's Smart NC program provides independent external review—and it's your strongest appeal option.

How Smart NC Works

Eligibility: State-regulated insurance plans (most individual and small group BCBS plans qualify)
Timeline: Must request within 120 days of final internal denial
Cost: Free to patients
Process: Independent Review Organization (IRO) evaluates your case
Decision timeline: 45 days standard, 72 hours expedited

Filing an External Review

  1. Call Smart NC: 1-855-408-1212 for guidance and forms
  2. Complete application: Available on NC Department of Insurance website
  3. Submit supporting documents: Medical records, denial letters, clinical literature
  4. IRO review: Independent medical experts evaluate your case
  5. Binding decision: If approved, BCBS must provide coverage within 3 business days
Note: Smart NC staff can help you complete the application and gather supporting evidence, but they cannot guarantee outcomes. However, North Carolina's external review program has helped many patients access expensive specialty medications.

Cost and Financial Assistance

Even with insurance approval, Tepezza can involve significant out-of-pocket costs.

Financial Assistance Options

Manufacturer Support:

  • Amgen By Your Side offers copay assistance and case management
  • Patient assistance programs for uninsured/underinsured patients

Foundation Grants:

  • Research patient assistance foundations that support rare disease treatments
  • Many require financial documentation and physician applications

Hospital Financial Aid:

  • Infusion centers often have charity care programs
  • Ask about payment plans and sliding fee scales

Templates and Scripts

Patient Phone Script for BCBS

"Hello, I'm calling about prior authorization for Tepezza for thyroid eye disease. My provider submitted the request on [date]. Can you tell me the status and what additional information might be needed? My member ID is [number]."

Medical Necessity Letter Template

Counterforce Health helps clinicians draft evidence-backed appeal letters by analyzing denial reasons and aligning responses to specific payer criteria. Their platform can streamline the complex documentation requirements for specialty drugs like Tepezza.

Key elements to include:

  • Patient demographics and insurance information
  • Detailed TED diagnosis with ICD-10 codes
  • Clinical Activity Score and proptosis measurements
  • Timeline of prior treatments and outcomes
  • FDA indication reference
  • Planned treatment protocol and monitoring

When to Escalate

Contact North Carolina regulators if you experience:

  • Repeated inappropriate denials despite meeting criteria
  • Failure to respond within required timeframes
  • Procedural violations during the appeal process

NC Department of Insurance Consumer Services:
Phone: 855-408-1212
Website: NCDOI Consumer Assistance

FAQ

How long does BCBS prior authorization take in North Carolina?
Standard review takes 5-14 business days. Expedited review (for urgent cases) takes up to 72 hours.

What if Tepezza is non-formulary on my BCBS plan?
File a formulary exception request with your prior authorization. Include medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal if my TED is worsening?
Yes. Provide documentation of rapid disease progression or risk of permanent vision loss to qualify for expedited review.

Does step therapy apply to Tepezza in North Carolina?
Many BCBS plans require documented failure of corticosteroids before approving Tepezza. Document any contraindications or intolerance to steroids.

What happens if Smart NC denies my external review?
The IRO decision is binding on insurance companies. If denied, explore other options like manufacturer assistance programs or legal consultation.

How do I find an in-network infusion center?
Use the BCBS provider directory online or call member services. Verify both the facility and administering physician are in-network.

Can I appeal if I move to North Carolina from another state?
Yes, but you'll need to establish care with a North Carolina specialist and may need to repeat some documentation requirements.

What if my employer plan is self-funded?
Self-funded plans may not be subject to North Carolina's external review process. Check with your HR department about appeal rights under your specific plan.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation.

For additional help navigating insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212 or visit the North Carolina Department of Insurance website for official forms and guidance.

Sources & Further Reading

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