By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Cigna in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Tepezza Covered by Cigna in Georgia

Cigna requires prior authorization for Tepezza (teprotumumab) in Georgia, with approval based on moderate-to-severe thyroid eye disease (TED) criteria. Standard review takes 5 business days; urgent cases can be expedited within 24-72 hours. If denied, you have 180 days to appeal internally, then 60 days for Georgia external review.

Fastest path to approval:

  1. Have your ophthalmologist or endocrinologist complete the Cigna Tepezza PA form
  2. Document moderate TED severity (proptosis ≥3mm, lid retraction ≥2mm, or diplopia)
  3. Submit via CoverMyMeds or fax to 855-840-1678, then call 1-800-882-4462 for urgent cases

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Medical Criteria Requirements
  5. Costs and Financial Assistance
  6. Denials and Appeals
  7. Renewals and Re-authorization
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Georgia-Specific Appeal Rights

Coverage Basics

Is Tepezza Covered by Cigna in Georgia?

Yes, Cigna covers Tepezza (teprotumumab-trbw) for thyroid eye disease when medical necessity criteria are met. Coverage applies to:

  • Commercial plans (employer and individual)
  • Medicare Advantage plans
  • Exchange plans through the federal marketplace

Tepezza is billed under HCPCS code J3241 as a medical benefit infusion drug, not a retail pharmacy benefit.

Which Plans Require Prior Authorization?

All Cigna plans in Georgia require prior authorization for Tepezza. The 2025 Cigna Healthcare Plus Georgia formulary marks specialty biologics with "PA" indicating prior authorization requirements.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm Your Plan Type
    • Check your Cigna ID card for plan name and member services number
    • Verify Tepezza is covered under medical benefit (not pharmacy)
  2. Schedule with the Right Specialist
    • Must be prescribed by ophthalmologist, endocrinologist, or TED specialist
    • Ensure provider documents all required clinical measurements
  3. Complete Prior Authorization Form
  4. Submit Authorization Request
    • Electronic: CoverMyMeds or SureScripts through EHR
    • Fax: 855-840-1678
    • Phone: 1-800-882-4462 for verbal PA or urgent requests
  5. Follow Up Within 48 Hours
    • Confirm receipt and obtain reference number
    • Ask for expected decision date
  6. Prepare for Infusion
  7. Monitor for Decision
    • Standard: 5 business days
    • Urgent: 24-72 hours (call to confirm expedited processing)

Timing and Urgency

Standard Review Timeline

Cigna's standard response time for Tepezza prior authorization is 5 business days from receipt of complete documentation.

Expedited/Urgent Review

For urgent cases, Cigna can expedite review to 24-72 hours. To qualify for urgent review:

  • Check the "Urgent" box on the PA form
  • Physician must attest that standard timeframes "may seriously jeopardize the customer's life, health, or ability to regain maximum function"
  • Call 1-800-882-4462 immediately after submitting to request expedited processing
Tip: Document urgent clinical scenarios like rapidly worsening proptosis, compressive optic neuropathy risk, or severe functional impairment affecting employment or daily activities.

Medical Criteria Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed
Diagnosis Thyroid Eye Disease (TED) ICD-10 codes, specialist notes
Age ≥18 years Date of birth verification
Severity Moderate-to-severe TED Clinical measurements (see below)
Prescriber Specialist required Ophthalmologist or endocrinologist
Dose Limit Maximum 8 infusions Treatment history documentation

Moderate-to-Severe TED Criteria

Cigna's policy IP0129 requires at least one of:

  • Lid retraction ≥2mm
  • Moderate/severe soft tissue involvement
  • Proptosis ≥3mm above normal for race/sex
  • Diplopia with Gorman score 2-3

Clinician Corner: Medical Necessity Letter Checklist

Essential elements for approval:

  • Specific TED diagnosis with ICD-10 codes
  • Objective measurements (Hertel exophthalmometry, lid measurements)
  • Clinical Activity Score (CAS) if disease is active
  • Functional impact on vision, work, daily activities
  • Prior treatments attempted (if any) and outcomes
  • Planned dosing: 8 infusions over 24 weeks
  • Monitoring plan for hearing, glucose, infusion reactions

Costs and Financial Assistance

Understanding Your Out-of-Pocket Costs

Tepezza is typically covered under your medical benefit with:

  • Deductible applies (if unmet)
  • Coinsurance of 10-40% of allowed amount
  • Out-of-pocket maximum caps annual costs

A full 8-infusion course can cost $350,000-$500,000+ before insurance, making cost-sharing potentially significant.

Financial Assistance Options

For Commercial Insurance:

For Medicare:

  • Manufacturer copay cards are prohibited
  • Explore Medicare Supplement insurance
  • Contact foundations like Patient Access Network or HealthWell Foundation
Note: Accredo specialty pharmacy coordinates benefit verification and financial assistance screening as part of their service.

Denials and Appeals

Common Denial Reasons & Fixes

Denial Reason How to Overturn
"Insufficient documentation of moderate disease" Submit detailed measurements, photos, CT/MRI results
"Not prescribed by appropriate specialist" Ensure ophthalmologist or endocrinologist signs PA
"Exceeds maximum dose limit" Clarify total prior Tepezza doses received
"Not medically necessary" Strengthen clinical rationale with functional impact

Appeals Process for Cigna in Georgia

Internal Appeals (First Level):

  • Deadline: 180 days from denial notice
  • Reviewer: Different clinician than original denial
  • Timeline: 30 days for standard, 72 hours for urgent
  • Submit to: Address on denial letter or member portal

Internal Appeals (Second Level):

  • Available if first appeal denied
  • Same timeline and submission process
  • Often includes peer-to-peer review option

Scripts & Templates

Patient Phone Script for Cigna: "I'm calling about my Tepezza prior authorization denial. My member ID is [ID]. I'd like to request a peer-to-peer review between my specialist and your medical director. Can you schedule that and provide me with the reference number?"

Clinic Staff Peer-to-Peer Script: "We're requesting a peer-to-peer review for Tepezza denial. The patient has moderate-to-severe TED with [specific measurements]. We can provide additional clinical documentation if needed."

Renewals and Re-authorization

When Re-authorization Is Needed

Cigna typically approves Tepezza for 6 months or completion of the 8-dose series. Re-authorization may be needed if:

  • Treatment course extends beyond initial approval period
  • Patient switches Cigna plans
  • Significant gap in treatment occurs

What Changes Require New PA

  • New insurance plan or policy year
  • Change in prescribing physician
  • Modification of treatment protocol
  • Addition of new medical conditions

Specialty Pharmacy Requirements

Why Tepezza Gets Transferred

Cigna often requires specialty biologics like Tepezza to be:

  • Dispensed through Accredo specialty pharmacy
  • Administered at Cigna Pathwell Specialty Network sites
  • Coordinated through specialty infusion centers

Working with Accredo

The Accredo Tepezza enrollment process includes:

  • Benefit verification and PA status check
  • Financial assistance screening
  • Coordination with infusion sites
  • Ongoing therapy management

Troubleshooting Common Issues

Portal and System Problems

If CoverMyMeds is down:

  • Fax PA form to 855-840-1678
  • Call 1-800-882-4462 for verbal submission
  • Keep fax confirmation for records

Missing Forms or Information:

  • Download current forms from Cigna provider portal
  • Verify fax numbers haven't changed
  • Request read receipts when possible

When Authorization Seems Delayed

  1. Call member services with PA reference number
  2. Ask for status update and expected decision date
  3. Request expedited review if clinically appropriate
  4. Document all interactions with dates and representative names

Georgia-Specific Appeal Rights

External Review Process

If Cigna upholds a denial after internal appeals, Georgia residents have the right to independent external review:

Key Details:

  • Deadline: 60 days from final internal denial
  • Cost: Free to consumer
  • Reviewer: Independent medical experts
  • Timeline: 30 business days (72 hours for urgent)
  • Decision: Binding on Cigna

How to Request External Review

Contact the Georgia Office of Commissioner of Insurance and Fire Safety:

Consumer Assistance Resources

Georgians for a Healthy Future:

  • Provides consumer assistance with insurance appeals
  • Offers guides and one-on-one help
  • Can refer to legal aid when needed

Georgia Legal Services Program:

  • Assists with Medicaid/PeachCare appeals
  • Provides legal representation in complex cases

FAQ: Most Common Questions

Q: How long does Cigna PA take for Tepezza in Georgia? A: Standard review is 5 business days. Urgent cases can be decided within 24-72 hours if you call 1-800-882-4462 to request expedited processing.

Q: What if Tepezza is non-formulary on my plan? A: Even non-formulary drugs can be covered through the medical necessity exception process. Work with your specialist to document why Tepezza is medically necessary and superior to alternatives.

Q: Can I get a temporary supply while PA is pending? A: For infusion drugs like Tepezza, temporary supplies aren't typically available. Focus on expedited review if treatment delay poses clinical risks.

Q: Does step therapy apply if I've failed treatments outside Georgia? A: Yes, prior treatment failures from other states count toward step therapy requirements. Ensure all medical records are transferred to your current specialist.

Q: What happens if I switch Cigna plans mid-treatment? A: You'll likely need a new PA for the new plan. Start the process early and request expedited review to avoid treatment interruption.

Q: How much will Tepezza cost with Cigna coverage? A: Costs vary by plan design. With commercial insurance, manufacturer copay assistance can significantly reduce out-of-pocket expenses. Medicare patients should explore foundation assistance.

When to Escalate

Contact Georgia insurance regulators if:

  • Cigna violates appeal timelines
  • You suspect wrongful denial patterns
  • Standard appeals processes fail

Georgia Department of Insurance Consumer Services:

  • Phone: 1-800-656-2298
  • Online: Insurance complaint form
  • Purpose: Ensure proper appeals processing and investigate insurer practices

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed letters that align with payer policies. Our platform analyzes denial letters and plan policies to identify the specific criteria needed for approval, then drafts point-by-point rebuttals with the right clinical evidence and regulatory citations.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan terms and clinical situation. Always consult your healthcare provider about treatment options and work with your insurance company directly for coverage determinations. For personalized assistance with appeals, consider working with Counterforce Health or other qualified patient advocacy services.

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