By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (teprotumumab) Covered by Cigna in Washington: Prior Authorization, Appeals, and Billing Guide

Quick Answer: Tepezza (teprotumumab) requires prior authorization through Cigna's Express Scripts/Accredo specialty pharmacy network. Submit clinical documentation including TED diagnosis (ICD-10: E05.00), disease severity assessment, and weight-based dosing justification. If denied, Washington residents can appeal through internal review, then external IRO review within 60 days. Start by having your eye specialist complete Cigna's PA form with supporting chart notes and lab results.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Thyroid Eye Disease
  3. Product Coding: HCPCS J3241 and Billing Units
  4. Clean Prior Authorization Request
  5. Frequent Billing Pitfalls
  6. Verification with Cigna Resources
  7. Appeals Process in Washington
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Tepezza (teprotumumab) is administered as an IV infusion and falls under the medical benefit rather than pharmacy benefit for most Cigna plans. This means it's billed using HCPCS J-codes rather than NDC numbers on pharmacy claims.

Coverage at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all Tepezza prescriptions Cigna PA requirements Cigna Policy
Formulary Status Specialty tier, non-preferred Express Scripts formulary Payer Portal
Site of Care Least intensive medically appropriate setting PA determination process Cigna Guidelines
Step Therapy May require corticosteroid trial Plan-specific criteria Member handbook
Billing Code HCPCS J3241 (10 mg units) CMS HCPCS database Medicare

The medical benefit pathway means your ophthalmologist or endocrinologist will handle the prior authorization and billing, typically through their infusion center or a contracted specialty pharmacy like Accredo.

ICD-10 Mapping for Thyroid Eye Disease

Proper diagnosis coding is crucial for Tepezza approval. Use these primary ICD-10 codes based on your clinical presentation:

Primary Diagnosis Codes:

  • E05.00: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis (most common for TED with active hyperthyroidism)
  • E05.01: Thyrotoxicosis with diffuse goiter with thyrotoxic crisis
  • E06.3: Autoimmune thyroiditis (for euthyroid TED cases)

Secondary Codes for Eye Manifestations:

  • H06.20: Thyrotoxic exophthalmos, unspecified eye
  • H06.21: Thyrotoxic exophthalmos, right eye
  • H06.22: Thyrotoxic exophthalmos, left eye

Documentation Requirements: Your medical record must include specific clinical findings that support these codes:

  • Measured proptosis (exophthalmos) in millimeters
  • Eyelid retraction measurements
  • Clinical Activity Score (CAS) if available
  • Thyroid function tests (TSH, free T4, TSI or TRAb)
  • Smoking history and current status
Tip: Document bilateral involvement even if one eye is more severely affected. Many insurance policies require evidence of "moderate to severe" disease, which bilateral involvement helps establish.

Product Coding: HCPCS J3241 and Billing Units

Tepezza is billed using HCPCS code J3241, where each unit represents 10 mg of teprotumumab. Here's how the math works:

Dosing Schedule:

  • First infusion: 10 mg/kg
  • Subsequent 7 infusions: 20 mg/kg every 3 weeks

Unit Calculation Example: For a 70 kg patient:

  • First dose: 70 kg × 10 mg/kg = 700 mg ÷ 10 = 70 units
  • Subsequent doses: 70 kg × 20 mg/kg = 1,400 mg ÷ 10 = 140 units

Required Modifiers:

  • JZ modifier: No drug wastage (required by Medicare since July 2023)
  • JW modifier: Document any discarded drug from single-use vials

NDC Information:

  • Primary NDC: 75987-0130-01 (500 mg vial)
  • Always verify current NDC with your distributor as these can change

The current wholesale acquisition cost is approximately $17,511 per 500 mg vial as of March 2025, making proper unit calculation critical for accurate billing.

Clean Prior Authorization Request

A complete Cigna prior authorization for Tepezza should include these elements:

Required Clinical Documentation:

  1. Letter of medical necessity from prescribing ophthalmologist or endocrinologist
  2. Chart notes documenting TED diagnosis and severity
  3. Laboratory results: TSH, free T4, TSI or TRAb antibodies
  4. Imaging studies: Orbital CT or MRI if available
  5. Clinical photographs: Before/after if previous treatment attempted
  6. Patient weight and calculation of weight-based dosing

Submission Methods:

  • Online: CoverMyMeds portal or EHR integration
  • Fax: 855-840-1678 (Cigna PA fax line)
  • Phone: 800-882-4462 for urgent requests

Response Timeline: Standard prior authorization decisions are issued within 5 business days. For urgent cases where delayed treatment could jeopardize vision, call the phone number above to request expedited review within 24 hours.

From our advocates: We've seen the fastest approvals when the ophthalmologist includes specific measurements (proptosis in mm, lid retraction in mm) and documents how TED impacts the patient's daily activities like driving or reading. Photos showing the severity of eye changes can be particularly compelling for reviewers.

Frequent Billing Pitfalls

Avoid these common errors that lead to claim denials:

Unit Conversion Mistakes:

  • Billing total mg instead of units (divide mg by 10)
  • Forgetting to round up partial units
  • Mixing up first dose (10 mg/kg) vs. maintenance dose (20 mg/kg)

Coding Errors:

  • Using old or incorrect HCPCS codes
  • Missing required JZ or JW modifiers
  • Mismatched ICD-10 codes (using H05.20 instead of H06.20 for thyrotoxic exophthalmos)

Documentation Issues:

  • Missing patient weight documentation
  • Inadequate clinical notes supporting medical necessity
  • Failure to document prior therapy failures where required

Timing Problems:

  • Submitting claims before PA approval
  • Missing step therapy documentation deadlines
  • Not updating PA for dose changes

Verification with Cigna Resources

Before submitting your prior authorization or claim, verify requirements using these Cigna resources:

Provider Resources:

Cross-Check Steps:

  1. Confirm J3241 is the current HCPCS code
  2. Verify your patient's specific plan formulary tier for Tepezza
  3. Check if step therapy requirements apply to your patient's diagnosis
  4. Confirm site-of-care requirements (office vs. hospital outpatient)
  5. Validate current PA form version and submission method

Many Cigna plans contract with Accredo for specialty drug management. If your PA is approved, Accredo may contact you directly to coordinate infusion logistics and patient support services.

Appeals Process in Washington

Washington state provides strong consumer protections for insurance denials, including specialty drug coverage disputes.

Internal Appeals with Cigna:

  • Timeline: File within 180 days of denial
  • Process: Submit written appeal with additional clinical evidence
  • Decision: Standard appeals decided within 30 days, expedited within 72 hours

External Review Process: If Cigna denies your internal appeal, Washington law entitles you to an independent external review through a certified Independent Review Organization (IRO).

External Review Timeline:

  • Request deadline: Within 60 days of final internal denial
  • IRO assignment: Cigna must assign IRO within 3 business days
  • Decision: Standard review within 20 days, expedited within 72 hours

How to Request External Review:

  1. Submit written request to Cigna (not directly to the state)
  2. Include any new clinical evidence not previously submitted
  3. Cigna forwards your case to a Washington-certified IRO
  4. The IRO's decision is binding on Cigna

Washington Insurance Commissioner Support:

For self-funded employer plans, different federal ERISA rules may apply, but many employers voluntarily use Washington's external review process.

Quick Audit Checklist

Before submitting your Tepezza prior authorization or claim, review this checklist:

Clinical Documentation:

  • Primary ICD-10 code (E05.00 or appropriate variant)
  • Secondary eye manifestation codes (H06.20-H06.22)
  • Current patient weight documented
  • TED severity assessment (CAS score if available)
  • Laboratory results supporting thyroid diagnosis
  • Prior therapy documentation if step therapy applies

Coding and Billing:

  • HCPCS J3241 with correct unit calculation
  • Appropriate modifier (JZ for no waste, JW for waste)
  • Current NDC number verified
  • Site of care matches PA approval

Administrative:

  • PA approval obtained before treatment
  • Patient insurance eligibility verified
  • Correct submission method (portal, fax, or phone)
  • All required forms completed and signed
  • Backup documentation organized for potential appeal

Patient Communication:

  • Patient informed of approval status
  • Financial responsibility explained
  • Alternative resources identified if denied (manufacturer support, patient assistance)

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Tepezza. Our platform analyzes denial letters, identifies the specific coverage criteria, and drafts evidence-backed appeals that address payers' exact requirements. For patients facing Cigna denials in Washington, we provide the clinical citations, procedural guidance, and documentation strategies that maximize approval chances while meeting state-specific appeal deadlines.

Frequently Asked Questions

How long does Cigna prior authorization take for Tepezza in Washington? Standard PA decisions are issued within 5 business days. Urgent requests can be expedited to 24 hours by calling 800-882-4462 and documenting immediate medical necessity.

What if Tepezza is not on my Cigna formulary? You can request a formulary exception through Cigna's standard process. Your ophthalmologist must provide clinical justification for why Tepezza is medically necessary and other treatments are inappropriate.

Does step therapy apply to Tepezza coverage? Many Cigna plans require documentation of corticosteroid trial and failure before approving Tepezza. Check your specific plan documents or have your provider verify current requirements.

Can I appeal a Tepezza denial in Washington? Yes. Washington provides internal appeals through Cigna and external review through independent organizations. You have 180 days to file internal appeals and 60 days after final denial for external review.

What happens if my Tepezza claim is denied after PA approval? If you have valid PA approval but claims are denied, this is typically a billing or coding error. Contact your provider's billing department to verify HCPCS codes, units, and modifiers match the PA approval.

Are there financial assistance programs for Tepezza? Amgen offers patient support programs through Amgen By Your Side. Eligibility varies based on insurance type and income.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and can change. Always verify current requirements with your insurance carrier and consult healthcare professionals for medical decisions. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 800-562-6900.

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