By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Blue Cross Blue Shield in Texas: Complete Prior Authorization Guide

Quick Answer: Getting Tepezza Covered by Blue Cross Blue Shield of Texas

Tepezza (teprotumumab) requires prior authorization from Blue Cross Blue Shield of Texas (BCBSTX) for thyroid eye disease coverage. The fastest path to approval: (1) Confirm your plan covers medical benefit drugs under HCPCS J3241, (2) gather clinical documentation showing moderate-to-severe TED with failed/contraindicated steroid therapy, and (3) submit the complete prior authorization packet through your ophthalmologist or endocrinologist. Start by downloading BCBSTX's current PA form and verifying your plan's medical drug benefit coverage at bcbstx.com.

Table of Contents

Before You Start: Plan Verification

Confirm Your Coverage Type

Blue Cross Blue Shield of Texas offers different plan types with varying coverage rules:

  • Commercial/Individual plans: Follow BCBSTX medical drug policies
  • Employer self-funded plans: May have custom formularies (check with HR)
  • Medicare Advantage: Follow Medicare Part B rules with BCBSTX administration
  • Medicaid managed care: Different PA requirements and timelines
Tip: Call the number on your insurance card to confirm whether Tepezza is covered under your medical benefit and what prior authorization requirements apply.

Check Medical vs. Pharmacy Benefit

Tepezza is billed using HCPCS code J3241 under the medical benefit, not your prescription drug coverage. This means:

  • It's administered as an infusion in a clinical setting
  • Your medical deductible and coinsurance apply
  • Specialty pharmacy distribution is typically required
  • Site-of-care restrictions may apply (office/infusion center preferred over hospital outpatient)

What You Need to Gather

Clinical Documentation Requirements

For your ophthalmologist or endocrinologist to include:

  • Diagnosis confirmation: ICD-10 codes for thyroid eye disease
  • Disease activity: Clinical Activity Score (CAS) of ≥3/7 showing active inflammation
  • Objective measurements: Proptosis measurements using Hertel exophthalmometer (typically >18-20mm for Caucasians, >16-18mm for Asians, >20-22mm for African-Americans)
  • Severity documentation: Moderate-to-severe TED with functional impact
  • Prior therapy history: Detailed documentation of systemic corticosteroid trial, including dose, duration, response, and reasons for discontinuation or contraindication
  • Current thyroid status: Recent lab results (within 30 days) showing euthyroid or controlled thyroid function
  • Supporting evidence: Clinical photographs, visual field testing if applicable, quality-of-life impact assessment

Administrative Documents

  • Current insurance card and policy information
  • BCBSTX prior authorization form (download from provider portal)
  • Prescriber's DEA number and NPI
  • Preferred infusion site information

Step-by-Step: Fastest Path to Approval

Step 1: Specialist Evaluation

Who does it: Patient schedules with ophthalmologist (preferably oculoplastic surgeon) or endocrinologist Timeline: 1-2 weeks for appointment What happens: Complete TED assessment including CAS scoring and proptosis measurement

Step 2: Document Prior Treatments

Who does it: Physician reviews medical history What's needed: Specific details about steroid therapy (drug name, dose, duration, side effects, efficacy) Timeline: Same visit or chart review

Step 3: Lab Work

Who does it: Patient gets blood drawn What's needed: TSH, free T4, T3 (must be within 30 days of PA submission) Timeline: 1-3 days for results

Step 4: Complete PA Form

Who does it: Physician's office What's included: All clinical documentation, photos, lab results, prior therapy details Timeline: 1-2 business days to compile

Step 5: Submit to BCBSTX

Who does it: Physician's office or specialty pharmacy How: Fax, online portal, or mail Timeline: Same day submission

Step 6: Follow Up

Who does it: Patient and physician's office When: 5-7 business days after submission What to ask: PA status, reference number, any missing information

Step 7: Coordinate Specialty Pharmacy

Who does it: Physician's office coordinates with BCBSTX-contracted specialty pharmacy Timeline: 1-2 weeks after approval What happens: Drug procurement and infusion scheduling

Submitting Your Request

BCBSTX Submission Methods

Online Portal (preferred for fastest processing):

  • Provider portal at bcbstx.com
  • Electronic prior authorization through CoverMyMeds

Fax Submission:

  • Prior authorization fax number (verify current number with BCBSTX)
  • Include cover sheet with member ID and drug name

Mail Submission: Blue Cross and Blue Shield of Texas Prior Authorization Department P.O. Box 660717 Dallas, TX 75266-0717

Clean Request Packet Checklist

  • Completed PA form with all required fields
  • Clinical notes with CAS scoring
  • Proptosis measurements with instrument type noted
  • Recent thyroid function labs (≤30 days)
  • Prior steroid therapy documentation
  • Clinical photographs (if available)
  • Prescriber's signature and date

Following Up and Timelines

Texas-Mandated Response Times

Standard Prior Authorization: 30 days for pre-service requests Expedited Review: 72 hours (requires medical urgency documentation) Post-service Appeals: 60 days for review

Sample Follow-Up Call Script

"Hi, I'm calling to check on the status of a prior authorization for Tepezza submitted on [date]. The member ID is [number] and the reference number is [if available]. Can you tell me the current status and whether any additional information is needed?"

Document everything: Date, time, representative name, reference numbers, and any requests for additional information.

If You Need More Information

Common Information Requests

Medical Necessity Questions: BCBSTX may ask for additional clinical justification. Have your physician prepare a detailed letter addressing:

  • Why Tepezza is medically necessary for your specific case
  • Why alternative treatments are inappropriate or have failed
  • Expected clinical outcomes and monitoring plan

Additional Documentation: May include recent imaging studies, additional lab work, or consultation notes from other specialists.

Note: Response time for additional information requests is typically 10-14 days. Missing this deadline can result in automatic denial.

When You're Denied: Appeals Process

Internal Appeal Process

Filing Deadline: 60 days from denial notice date Who can file: Patient, physician, or authorized representative Required information: Original denial letter, new clinical information, detailed rebuttal

Contact Information: Phone: 1-888-657-6061 (Mon-Fri, 8 a.m. to 5 p.m. CT) Fax: 1-855-235-1055 Mail: Blue Cross and Blue Shield of Texas ATTN: Complaints and Appeals Department P.O. Box 660717 Dallas, TX 75266-0717

Expedited Appeals

For urgent cases where delay could jeopardize health:

  • Decision within 72 hours
  • Requires physician statement of medical urgency
  • Can be filed simultaneously with standard appeal

Renewal and Re-authorization

When to Re-authorize

Tepezza is typically approved for one complete course (8 infusions over 21 weeks). Re-authorization for additional courses requires:

  • Documentation of incomplete response to initial course
  • Evidence of continued disease activity
  • Updated clinical assessments and imaging

Calendar Reminders

  • Set reminder 30 days before final infusion
  • Gather updated clinical documentation
  • Submit renewal request 2-3 weeks before last scheduled dose

Common Denial Reasons & Solutions

Denial Reason How to Fix Documentation Needed
Incomplete prior authorization Resubmit with all required fields completed Complete PA form with physician signature
Insufficient clinical documentation Provide detailed clinical notes CAS scoring, proptosis measurements, photos
No documented steroid failure Submit prior therapy history Specific drug, dose, duration, side effects
Lab work too old Obtain current thyroid function tests TSH, T4, T3 within 30 days
Wrong specialist Transfer to ophthalmologist or endocrinologist Specialist evaluation and prescription
Billing code error Correct to J3241 for medical benefit Proper HCPCS coding

Costs and Patient Assistance

Out-of-Pocket Costs

With BCBSTX coverage, your costs depend on:

  • Medical deductible (typically $1,000-$5,000)
  • Coinsurance percentage (usually 10-30%)
  • Out-of-pocket maximum

Example: With a $2,000 deductible and 20% coinsurance, patient responsibility could range from $10,000-$25,000 for a full course.

Financial Assistance Options

Amgen By Your Side: Manufacturer patient assistance program

  • Copay assistance for eligible commercial insurance patients
  • Free drug program for qualifying uninsured patients
  • Phone: 1-833-TEPEZZA (1-833-837-3992)

Foundation Grants: Organizations like the National Organization for Rare Disorders (NORD) may provide assistance for qualifying patients.

At Counterforce Health, we help patients navigate these complex prior authorization processes by analyzing denial letters and crafting targeted, evidence-backed appeals that address specific payer requirements. Our platform turns insurance denials into successful approvals by ensuring all clinical documentation meets Blue Cross Blue Shield's exact criteria for Tepezza coverage.

Texas-Specific Appeal Rights

Independent Review Organization (IRO)

If BCBSTX denies your internal appeal, Texas law provides additional protection:

External Review Rights:

  • Available for medical necessity denials
  • Must be requested within 4 months of final internal denial
  • No cost to patient (insurer pays IRO fees)
  • Decision is binding on BCBSTX

Expedited External Review:

  • Available for urgent cases
  • Decision within 5 days
  • Can be filed without completing internal appeals if urgent

Contact Information: Texas Department of Insurance 1-800-252-3439 IRO Information Line: 1-866-554-4926

State Resources for Help

Texas Department of Insurance (TDI):

  • Consumer assistance with insurance disputes
  • Website: tdi.texas.gov
  • Phone: 1-800-252-3439

Office of Public Insurance Counsel (OPIC):

  • Free guidance on appealing denied claims
  • Phone: 1-877-611-6742

Quick Reference Checklist

Before Starting:

  • Confirm medical benefit coverage for J3241
  • Identify in-network ophthalmologist or endocrinologist
  • Verify current PA form from BCBSTX

Clinical Requirements:

  • TED diagnosis with ICD-10 codes
  • CAS score ≥3/7 documented
  • Proptosis measurements recorded
  • Steroid therapy history detailed
  • Recent thyroid labs (≤30 days)

Submission:

  • Complete PA form
  • All supporting documentation attached
  • Submitted via preferred method (portal/fax)
  • Reference number obtained

Follow-Up:

  • Status check at 5-7 days
  • Response to information requests within 10 days
  • Appeal filed within 60 days if denied

FAQ

How long does BCBSTX prior authorization take for Tepezza? Standard PA decisions are made within 30 days. Expedited reviews (for urgent cases) are completed within 72 hours. Complex cases requiring additional clinical review may take the full 30 days.

What if Tepezza is not on my BCBSTX formulary? Tepezza is billed under the medical benefit (J3241), not the prescription formulary. Check your medical drug benefit coverage rather than your prescription drug list.

Can I request an expedited appeal in Texas? Yes, if waiting for standard processing would jeopardize your health. Your physician must provide documentation of medical urgency. Expedited appeals are decided within 72 hours.

Does step therapy apply if I tried steroids outside Texas? Yes, prior steroid therapy from any location counts toward step therapy requirements, provided you have documentation of the treatment details and outcomes.

What happens if BCBSTX denies my appeal? Texas law provides access to Independent Review Organization (IRO) external review at no cost. The IRO's decision is binding on BCBSTX and must be requested within 4 months of the final internal denial.

Can family members help with my appeal? Yes, family members can act as authorized representatives with proper documentation. BCBSTX provides forms for designating representatives to handle appeals on your behalf.

From our advocates: We've seen the strongest Tepezza approvals come from cases where the specialist takes time to document not just the clinical measurements, but the real-world impact on the patient's daily life. A detailed letter explaining how TED affects work, driving, or social activities often makes the difference between approval and denial.

For complex denials or appeals, Counterforce Health specializes in turning insurance rejections into targeted, evidence-backed approvals by analyzing payer-specific requirements and crafting appeals that address each denial reason with the right clinical evidence and regulatory citations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield of Texas plan and consult with your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact qualified patient advocacy services.

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