By Counterforce Health Team in Tepezza (teprotumumab) —

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

Quick Answer: Getting Tepezza Approved by Cigna in Virginia

Cigna requires prior authorization for Tepezza (teprotumumab) in Virginia. Your fastest path: Have your ophthalmologist or endocrinologist submit a PA request with documented moderate-to-severe thyroid eye disease (TED), including objective measurements and functional impact. If denied, you have 180 days to appeal internally, then 120 days for Virginia's external review through the State Corporation Commission. Start today by verifying your coverage and gathering clinical documentation.

Table of Contents

  1. Understanding Your Cigna Denial
  2. Cigna's Tepezza Coverage Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Virginia Appeals Process
  6. Medical Necessity Documentation
  7. Costs and Financial Assistance
  8. When to Escalate Beyond Cigna
  9. Frequently Asked Questions

Understanding Your Cigna Denial

When Cigna denies Tepezza coverage, your denial letter will specify the reason and your appeal rights. The most common denial categories include:

  • Prior authorization not obtained - You need approval before treatment
  • Medical necessity not established - Clinical criteria not met
  • Non-formulary drug - Tepezza isn't on your plan's preferred drug list
  • Step therapy required - Must try other treatments first
Note: Tepezza is billed under medical benefit using HCPCS code J3241, not through pharmacy benefits. This affects which appeal process applies.

Your denial letter contains critical information:

  • Denial reason and policy cited
  • Appeal deadline (typically 180 days for commercial Cigna plans)
  • Peer-to-peer review contact number
  • Required forms and submission methods

Cigna's Tepezza Coverage Requirements

Cigna requires prior authorization for all Tepezza treatment under policy IP0129. Here are the key criteria:

Coverage Criteria Table

Requirement Details Documentation Needed
Age ≥18 years Date of birth verification
Diagnosis Thyroid Eye Disease (TED) ICD-10 codes, specialist notes
Severity Moderate-to-severe TED Objective measurements (see below)
Prescriber Ophthalmologist or endocrinologist Specialist credentials
Duration 6-month approval (8 infusions) Treatment plan documentation

Moderate-to-Severe TED Criteria

Cigna requires at least one of the following:

  • Lid retraction ≥2 mm above normal
  • Moderate/severe soft tissue involvement (eyelid swelling, conjunctival redness)
  • Proptosis ≥3 mm above normal for race and sex
  • Diplopia with Gorman score 2-3
Important: As of May 1, 2024, Cigna removed the requirement for "active" disease, making approval easier for patients with chronic TED.

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage

  • Call the number on your Cigna ID card
  • Confirm Tepezza is covered under medical benefit (not pharmacy)
  • Ask about your specific plan's PA requirements

2. Gather Clinical Documentation

Your specialist needs to document:

  • Clinical Activity Score (CAS) if disease is active
  • Proptosis measurements using Hertel exophthalmometry
  • Visual function assessment (acuity, motility, diplopia)
  • Photographs showing eye changes and functional impact
  • Prior treatments tried and outcomes

3. Submit Prior Authorization

Your doctor submits the PA request via:

  • CoverMyMeds portal (preferred)
  • Fax: 855-840-1678
  • Phone: 1-800-882-4462 for urgent cases

Timeline: Standard PA decisions within 5 business days; urgent cases within 24-72 hours.

4. If Approved

  • Specialty pharmacy coordination: Tepezza must be obtained through Cigna's Accredo network
  • Infusion scheduling: Coordinate with your infusion center
  • Monitoring requirements: Baseline hearing assessment, glucose monitoring

5. If Denied

  • Request peer-to-peer review immediately
  • File internal appeal within 180 days
  • Gather additional evidence to strengthen your case

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
Insufficient severity documentation Submit objective measurements Hertel exophthalmometry, lid measurements, photos
Missing specialist evaluation Obtain ophthalmology/endocrinology consult Specialist notes with credentials
Inadequate prior treatment history Document previous therapies Records of steroids, radiation, surgery attempts
Coding/billing errors Verify J3241 units calculation Weight-based dosing documentation
Non-formulary status Request formulary exception Medical necessity letter explaining alternatives tried
From our advocates: We've seen many Tepezza denials overturned when providers include high-quality photographs showing functional impairment alongside objective measurements. Visual documentation of how TED affects daily activities like driving or reading can be particularly compelling to reviewers.

Virginia Appeals Process

Virginia provides robust appeal rights through multiple levels:

Internal Appeals (Cigna)

Level 1 Internal Appeal

  • Deadline: 180 days from denial notice
  • Timeline: Cigna decides within 30 days for medical necessity cases
  • How to file: Written appeal via mail, fax, or online portal
  • Who reviews: Different clinical reviewer than initial denial

Level 2 Internal Appeal (if available)

  • Deadline: 60 days from Level 1 denial
  • Timeline: 45 days for Cigna decision
  • Reviewer: Independent committee or external medical director

Virginia External Review

After exhausting Cigna's internal appeals, Virginia law provides external review through the State Corporation Commission.

Key Details:

  • Deadline: 120 days from final internal denial
  • Form: External Review Request (Form 216-A)
  • Timeline: 45 days for standard review; 72 hours for expedited
  • Cost: Free to consumers
  • Decision: Binding on Cigna

How to File:

  1. Complete Form 216-A from Virginia SCC
  2. Include final denial letters and supporting medical records
  3. Submit to Virginia State Corporation Commission Bureau of Insurance
  4. SCC assigns Independent Review Organization (IRO)

Expedited Review Available When:

  • Life-threatening condition
  • Serious jeopardy to health or ability to regain function
  • Ongoing treatment where delays cause harm
Tip: Virginia allows expedited external review for cancer treatment denials without exhausting internal appeals—a unique patient protection.

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

A strong medical necessity letter should include:

Patient Assessment:

  • Confirmed TED diagnosis with ICD-10 codes
  • Clinical Activity Score (CAS) if active disease
  • Objective measurements (proptosis, lid retraction, motility)
  • Functional impact on vision and daily activities

Treatment History:

  • Prior therapies attempted (steroids, radiation, surgery)
  • Outcomes and reasons for discontinuation
  • Contraindications to standard treatments

Tepezza Rationale:

  • Why Tepezza is medically necessary for this patient
  • Expected outcomes based on clinical trials
  • Monitoring plan for side effects

Supporting Evidence:

  • FDA labeling for TED indication
  • Clinical practice guidelines
  • Peer-reviewed studies supporting use

Required Clinical Measurements

Proptosis Assessment:

  • Use Hertel exophthalmometry every 4-6 months
  • Document baseline and changes ≥2 mm
  • Compare to normal values for patient's race and sex

Clinical Activity Score (CAS):

  • 7-point scale for initial assessment
  • 10-point scale for follow-up visits
  • CAS ≥3 indicates active inflammation

Photography:

  • Baseline photos showing eye position and appearance
  • Follow-up photos demonstrating progression
  • Include functional positions (upgaze, downgaze, reading position)

Costs and Financial Assistance

Treatment Costs

  • Full course: $350,000-$500,000+ before insurance
  • Patient responsibility: Deductible plus 10-40% coinsurance until out-of-pocket maximum
  • Per vial cost: Approximately $17,511 (500mg vial)

Financial Assistance Options

Manufacturer Support:

  • Amgen By Your Side program
  • Copay assistance for eligible commercial insurance patients
  • Patient access specialists for coverage support

Specialty Pharmacy Support:

  • Accredo provides benefit verification and prior authorization assistance
  • Financial counseling and payment plan options
  • Coordination with manufacturer programs

Foundation Grants:

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

When to Escalate Beyond Cigna

Virginia Insurance Regulators

State Corporation Commission Bureau of Insurance

  • Phone: 1-877-310-6560
  • Website: scc.virginia.gov
  • Services: External review, consumer complaints, plan oversight

Virginia Managed Care Ombudsman

  • Part of SCC Consumer Services
  • Assists with HMO and managed care plan issues
  • Can informally resolve disputes before formal appeals

When to File a Complaint

  • Cigna violates appeal timelines
  • Improper denial of expedited review
  • Failure to provide required notices
  • Suspected bad faith claim handling
  • Virginia Poverty Law Center - Health Assistance program
  • Legal Aid Society - For low-income patients
  • Private attorneys - For complex cases or potential bad faith claims

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for complex specialty medications like Tepezza. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific payer criteria. We help clinicians draft compelling medical necessity letters, gather the right clinical evidence, and navigate Virginia's appeal process—saving time and improving approval rates for patients who need life-changing treatments.

Frequently Asked Questions

How long does Cigna prior authorization take for Tepezza in Virginia? Standard PA decisions within 5 business days. Urgent cases decided within 24-72 hours if medical necessity is documented.

What if Tepezza is not on my Cigna formulary? Request a formulary exception with medical necessity documentation. Cigna reviews non-urgent exceptions within 72 hours.

Can I get an expedited appeal in Virginia? Yes, if your doctor certifies that waiting could seriously jeopardize your health. Expedited reviews decided within 72 hours.

Does step therapy apply to Tepezza in Virginia? Some plans require trying steroids or other treatments first. Document failures or contraindications to bypass step therapy.

What happens if I switch Cigna plans during treatment? You'll need new prior authorization. Start the process before your plan change effective date to avoid treatment delays.

How do I find a TED specialist in Virginia? Contact the American Thyroid Association or Thyroid Eye Disease Society for specialist referrals in your area.

Can I appeal if my employer's self-funded plan denies Tepezza? Virginia's external review may apply if your employer opts in. Otherwise, federal external review through HHS is available.

What if Cigna approves fewer than 8 infusions? Appeal the quantity limitation with documentation supporting the full FDA-approved regimen of 8 infusions over 24 weeks.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and your insurance company about specific coverage policies. Appeal rights and procedures may vary by plan type and can change. For the most current information, contact Counterforce Health or Virginia's State Corporation Commission directly.

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