By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (teprotumumab) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Tepezza Covered by Blue Cross Blue Shield in Washington

Fastest path: Submit prior authorization with complete TED documentation (CAS score, photos, euthyroid labs, ophthalmologist prescription). If denied, file internal appeal within plan deadlines, then request IRO external review through Washington's Office of Insurance Commissioner (1-800-562-6900). Success rates for specialty drug appeals via IRO are 40-45% in Washington.

Start today: Call your Blue Cross plan's prior authorization line, request current Tepezza coverage criteria, and begin gathering clinical documentation with your ophthalmologist.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Playbook for Blue Cross Blue Shield in Washington
  5. Clinician Corner: Medical Necessity Documentation
  6. Costs and Patient Assistance Programs
  7. When to Escalate to Washington State Regulators
  8. FAQ: Common Questions About Tepezza Coverage

Tepezza (teprotumumab) represents a breakthrough treatment for thyroid eye disease (TED), but getting this $350,000+ therapy covered by Blue Cross Blue Shield in Washington requires careful navigation of prior authorization requirements and potential appeals. This guide walks you through the complete process, from initial submission to external review if needed.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before treatment Premera PA portal or Regence provider portal Plan-specific
Formulary Status Specialty tier, medical benefit Plan formulary documents Washington Healthplanfinder
Diagnosis Code ICD-10 for TED (H05.20-H05.23) Clinical documentation FDA label
Prescriber Requirements Often requires ophthalmologist Plan medical policy Plan-specific
Duration Limits Typically 6 months maximum Plan coverage policy Premera medical policy
Billing Code J3241 (10 mg units) HCPCS coding CMS HCPCS

Step-by-Step: Fastest Path to Approval

1. Confirm Your Blue Cross Plan Type

Who: Patient Timeline: Same day Action: Identify whether you have Premera Blue Cross, Regence BlueShield, or another Blue Cross plan in Washington. Check your insurance card or call member services.

2. Request Current Prior Authorization Criteria

Who: Patient or clinic staff Timeline: 1-2 business days Action: Contact your plan's pharmacy services (Premera: 888-261-1756; Regence: check provider portal) to obtain current Tepezza coverage criteria and required forms.

3. Gather Clinical Documentation

Who: Patient with ophthalmologist Timeline: 1-2 weeks Required documents:

  • Complete TED diagnosis with ICD-10 codes
  • Clinical Activity Score (CAS) with objective measurements
  • Recent photographs showing proptosis/eye changes
  • Thyroid function tests (TSH, free T3, free T4) showing euthyroid status
  • Documentation of failed or contraindicated steroid therapy
  • Treatment plan specifying 8-infusion FDA-approved regimen

4. Submit Prior Authorization Request

Who: Prescribing physician or clinic Timeline: Submit within plan deadlines Method: Online portal, fax, or phone (plan-specific) Expected response: 5 calendar days (standard) or 48 hours (urgent)

5. Monitor Authorization Status

Who: Patient and clinic Timeline: Check within 3-5 days Action: Follow up if no response within plan timelines. Request expedited review if medically urgent.

6. If Approved: Schedule Treatment

Who: Patient with infusion center Action: Coordinate with specialty pharmacy and infusion center using J3241 billing code.

7. If Denied: Initiate Appeals Process

Who: Patient with physician support Timeline: Within plan-specified deadlines (typically 180 days) Action: File internal appeal with additional documentation, then external IRO review if needed.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not active TED" Submit recent CAS score ≥3 with photos Clinical exam notes, standardized photos, CAS calculation
"Not euthyroid" Provide current thyroid labs TSH, free T3, free T4 within normal ranges
"Steroid therapy not tried" Document steroid failure/contraindication Chart notes showing steroid trial outcomes or contraindications
"Wrong prescriber specialty" Confirm ophthalmologist credentials Provider licensing verification, specialty board certification
"Exceeds duration limits" Request medical necessity exception Detailed progress notes, treatment response documentation
"Experimental/investigational" Cite FDA approval for TED FDA approval letter, official labeling

Appeals Playbook for Blue Cross Blue Shield in Washington

Internal Appeals Process

Level 1: Standard Internal Appeal

  • Deadline: 180 days from denial date
  • Timeline: 30 days for decision (15 days for urgent)
  • Submission: Plan member portal, fax, or certified mail
  • Required: Completed appeal form, denial letter, additional clinical evidence

Level 2: Peer-to-Peer Review (if available)

  • Who initiates: Prescribing physician
  • Timeline: Usually within 72 hours of request
  • Preparation: Review plan's specific Tepezza criteria, prepare clinical rationale

External Review (IRO Process)

When to file: After exhausting internal appeals Deadline: 4 months from final internal denial Cost: Free to patients Process:

  1. Contact Washington Office of Insurance Commissioner at 1-800-562-6900
  2. Submit IRO request with all documentation
  3. IRO assigns independent medical reviewer
  4. Decision within 30 days (72 hours if expedited)
  5. Decision is binding on insurer
From our advocates: We've seen Tepezza denials overturned at the IRO level when patients submitted comprehensive clinical packages including objective TED measurements and clear documentation of steroid therapy failures. The key is addressing every specific criterion in the plan's medical policy with corresponding clinical evidence.

Clinician Corner: Medical Necessity Documentation

Essential Elements for Tepezza Medical Necessity Letter

Patient Information:

  • Full name, DOB, policy number
  • Primary and secondary diagnoses with ICD-10 codes
  • Date of TED onset and progression timeline

Clinical Justification:

  • Objective TED severity measurements (proptosis in mm, diplopia assessment)
  • Clinical Activity Score (CAS) calculation with supporting findings
  • Impact on vision, daily activities, and quality of life
  • Photographic documentation of eye changes

Treatment History:

  • Previous therapies attempted (corticosteroids, other immunosuppressants)
  • Outcomes, side effects, or contraindications to standard treatments
  • Rationale for why alternatives are inappropriate

Tepezza-Specific Requirements:

  • Confirmation of euthyroid status with recent lab values
  • Treatment plan for 8-infusion FDA-approved regimen
  • Expected outcomes and monitoring plan
  • Site of care and administration details

Supporting Evidence:

  • Reference FDA approval for TED
  • Cite relevant clinical guidelines or peer-reviewed studies
  • Include patient-specific clinical photographs when appropriate

Template Resources

Physicians can access customizable appeal letter templates through Tepezza HCP resources and Amgen By Your Side support programs.

Costs and Patient Assistance Programs

Typical Treatment Costs:

  • Drug cost alone: $350,000-$500,000+ for complete 8-infusion course
  • Single vial: ~$17,600 (current WAC pricing)
  • Additional costs: Infusion center fees, monitoring, pre-medications

Financial Assistance Options:

Amgen Support Programs:

  • Amgen By Your Side: Coverage support, copay assistance, patient navigation
  • Eligibility: Varies by insurance type and income

Hospital Charity Care:

  • Washington hospitals required to offer charity care programs
  • Income-based discounts or free care
  • Apply directly through hospital financial counselors

Pharmaceutical Foundations:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)
  • Check eligibility requirements and application deadlines

When to Escalate to Washington State Regulators

Contact the Washington Office of Insurance Commissioner if you experience:

Procedural Violations:

  • Plan exceeds response timelines without justification
  • Denial of expedited review for urgent medical situations
  • Failure to provide clear denial rationales or appeal rights information

Contact Information:

  • Consumer Advocacy Hotline: 1-800-562-6900
  • Online complaint filing: Available through OIC website
  • Email support for complex cases

What to Include in Complaints:

  • Complete timeline of prior authorization and appeal attempts
  • All correspondence with the insurance plan
  • Clinical documentation supporting medical necessity
  • Evidence of plan policy violations or unreasonable delays

The OIC can provide guidance on appeal processes, investigate plan practices, and help navigate the IRO external review system.

FAQ: Common Questions About Tepezza Coverage

Q: How long does Blue Cross prior authorization take for Tepezza in Washington? A: Standard reviews typically take 5 calendar days for Premera, with urgent reviews processed within 48 hours. Regence follows similar timelines per Washington state requirements.

Q: What if Tepezza isn't on my Blue Cross formulary? A: You can request a formulary exception through your plan's standard process. This requires demonstrating medical necessity and often showing that formulary alternatives are inappropriate or have failed.

Q: Can I get expedited approval if my TED is rapidly worsening? A: Yes. If your physician certifies that delays could seriously jeopardize your health, you can request expedited prior authorization and appeals. Document the urgency with clinical evidence.

Q: Does step therapy apply to Tepezza in Washington Blue Cross plans? A: Many plans require documentation of steroid therapy failure or contraindication before approving Tepezza. This isn't always formal "step therapy" but functions similarly in practice.

Q: What happens if my IRO appeal is denied? A: IRO decisions are binding on insurers, but if denied, you may consider legal consultation. The IRO decision represents the final level of insurance appeals in Washington.

Q: Can I continue Tepezza treatment beyond 6 months if it's working? A: Extended treatment beyond the FDA-approved 8-infusion regimen is typically considered investigational by most plans, including Blue Cross plans in Washington, making coverage unlikely.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Tepezza. Our platform analyzes denial letters and plan policies to create targeted, evidence-based appeals that address payers' specific requirements. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process with higher success rates and less administrative burden.

For patients facing Tepezza denials in Washington, Counterforce Health can provide personalized appeal strategies that align with Blue Cross Blue Shield policies and Washington state regulations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance plan directly for specific coverage determinations. For personalized assistance with Washington insurance appeals, contact the Office of Insurance Commissioner at 1-800-562-6900.

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