By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (teprotumumab) Covered by Humana in Georgia: Complete Prior Authorization and Appeals Guide

Quick Answer: Humana requires prior authorization for Tepezza (teprotumumab) for thyroid eye disease in Georgia. Submit your PA request through CoverMyMeds or Humana's provider portal with complete TED documentation: CAS score ≥4, thyroid labs within 30 days, prior therapy history, and ophthalmology notes. If denied, appeal within 65 days and request Georgia external review within 60 days of final denial. Start by gathering your clinical records and confirming your prescriber is in-network.

Table of Contents

Plan Types & Network Requirements

Humana offers both HMO and PPO Medicare Advantage plans in Georgia, and your plan type affects how you access Tepezza treatment.

HMO Plans (Humana Gold Plus)

  • Referral required: You must get a referral from your primary care provider (PCP) to see an ophthalmologist or endocrinologist
  • Network restrictions: Must use in-network providers; out-of-network care not covered except emergencies
  • Common plans: Humana Gold Plus H4141-015, H4141-017

PPO Plans (HumanaChoice, Regional PPO)

  • No referrals needed: See any in-network specialist directly
  • Flexible network: Lower costs in-network, higher costs (but still covered) out-of-network
  • Common plans: HumanaChoice H5216-157, Regional PPO R0110-019
Tip: Use Humana's provider directory or call 1-833-704-1024 to confirm your ophthalmologist is in-network before starting the PA process.

Formulary Status & Coverage Rules

Tepezza is covered under Humana's medical benefit (not pharmacy benefit) and requires prior authorization across all plan types in Georgia.

Coverage Details

Element Status Requirements
Formulary Status Medical benefit coverage Prior authorization required
HCPCS Code J3241 (10 mg units) 500 mg vial = 50 units
Administration Infusion centers only In-network facility required
Specialty Pharmacy CenterWell Specialty Pharmacy Coordinates with infusion sites

The drug falls under Humana's high-cost medication review process, with prior authorization mandated for all lines of business as of 2025.

Prior Authorization Requirements

Humana's PA criteria for Tepezza align with FDA labeling but require comprehensive documentation of thyroid eye disease severity and treatment history.

Clinical Documentation Checklist

Diagnosis Requirements:

  • Confirmed thyroid eye disease (TED) diagnosis by ophthalmologist
  • Clinical Activity Score (CAS) ≥4 documented per eye
  • Proptosis measurements in millimeters
  • Appropriate ICD-10 codes for endocrine exophthalmos

Laboratory Requirements:

  • Thyroid function tests within 30 days (TSH, free T4)
  • Documentation of euthyroid or near-euthyroid status
  • Autoimmune markers (TSI/TRAb) if available

Treatment History:

  • Prior therapy attempts with corticosteroids (dates, doses, outcomes)
  • Documentation of treatment failure, inadequate response, or contraindications
  • Any orbital radiation or surgical interventions

Prescriber Requirements:

  • Ophthalmologist or endocrinologist
  • In-network provider strongly preferred
  • Weight-based dosing calculation included

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Network Status

Who does it: Patient or clinic staff
Timeline: 1-2 business days
Action: Confirm Humana eligibility and verify ophthalmologist is in-network via Humana's provider portal

2. Gather Clinical Documentation

Who does it: Clinic staff
Timeline: 3-5 business days
Documents needed:

  • Recent ophthalmology notes with CAS scoring
  • Thyroid labs within 30 days
  • Prior treatment records (steroids, other therapies)
  • Current weight for dosing calculations

3. Submit PA Request

Who does it: Prescriber or clinic staff
Portal: CoverMyMeds or Humana provider portal
Timeline: Same-day submission possible
Required: Complete Humana Tepezza PA form with all clinical attachments

4. Monitor Status and Respond to Requests

Who does it: Clinic staff
Timeline: Check every 3-5 business days
Action: Respond promptly to any Humana requests for additional information

5. Coordinate with Specialty Pharmacy

Who does it: Patient with clinic support
Timeline: 1-2 weeks after approval
Action: Work with CenterWell Specialty Pharmacy for drug procurement and delivery to infusion site

6. Schedule Infusions

Who does it: Patient
Timeline: Based on clinic availability
Schedule: 8 infusions over 21 weeks (initial 10 mg/kg, then 20 mg/kg every 3 weeks)

7. Track Treatment and Billing

Who does it: Clinic billing staff
Timeline: Ongoing
Action: Ensure proper HCPCS J3241 billing and monitor for any coverage issues

Note: Standard PA decisions typically take 72 hours to 14 days. Request expedited review if treatment delay poses health risks.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
CAS score not documented Submit detailed ophthalmology notes CAS ≥4 per eye with examiner signature
Not euthyroid Provide recent labs and endocrinology consultation TSH, free T4 within normal range or stable on therapy
Insufficient prior therapy Document steroid trials or contraindications Treatment dates, doses, outcomes, or medical contraindications
Out-of-network prescriber Request network exception or change providers Letter of medical necessity for specific provider
Incomplete dosing information Recalculate based on current weight Weight-based calculation: 10 mg/kg initial, 20 mg/kg subsequent

When preparing appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

Appeals Process in Georgia

Internal Appeal (First Level)

Timeline: 65 days from denial date
How to file: MyHumana portal, phone (number on ID card), or written submission
Required documents:

  • Original denial letter
  • Medical necessity letter from prescriber
  • Additional clinical evidence
  • Peer-reviewed literature supporting treatment

External Review (Georgia DOI)

Timeline: 60 days from final internal denial
How to file: Georgia Office of Insurance Commissioner application
Cost: Free to consumer
Decision timeline: 30 business days (72 hours if expedited)
Binding: Yes, on Humana

Important: Georgia's 60-day deadline for external review is shorter than the federal 120-day standard. Don't miss this critical window.

Escalation Options

  • Peer-to-peer review: Request before formal appeal
  • Georgia DOI Consumer Services: 1-800-656-2298 for assistance
  • Expedited review: Available if delay jeopardizes health

Cost-Share & Financial Assistance

Typical Medicare Advantage Costs

  • Deductible: Varies by plan (some $0 deductible plans available)
  • Coinsurance: Typically 20% of Medicare-allowed amount for Part B drugs
  • Out-of-pocket maximum: $8,850 for 2025 (in-network)

Financial Assistance Programs

  • Amgen By Your Side: Patient support program with potential copay assistance
  • Chronic Disease Fund: Grants for TED patients meeting income requirements
  • HealthWell Foundation: Copay assistance for autoimmune conditions
Note: Copay cards may not apply to Medicare plans. Check eligibility before assuming coverage.

FAQ

Q: How long does Humana PA approval take for Tepezza in Georgia?
A: Standard decisions take 72 hours to 14 days. Expedited reviews are available within 72 hours if treatment delay poses health risks. Track status via CoverMyMeds or Humana's provider portal.

Q: What if my ophthalmologist isn't in Humana's network?
A: HMO plans require in-network providers. PPO plans allow out-of-network care at higher cost. You can request a network exception with a letter of medical necessity explaining why the specific provider is required.

Q: Can I appeal if Humana says Tepezza is experimental?
A: Yes. Tepezza has full FDA approval for TED regardless of activity or duration. Submit the FDA label and peer-reviewed efficacy studies with your appeal. This is often a successful overturn reason.

Q: Does step therapy apply to Tepezza in Georgia?
A: Humana typically requires documentation of prior corticosteroid therapy or contraindications, but not formal step therapy through multiple biologics. Document why steroids failed or aren't appropriate.

Q: What's the difference between internal and external appeals in Georgia?
A: Internal appeals go through Humana's review process (65-day deadline). External reviews go through Georgia's Department of Insurance with independent physicians (60-day deadline, free, binding on Humana).

Q: Can I get temporary coverage while appealing?
A: New Humana members may get up to 30-day temporary supply of covered drugs. For ongoing treatment, request expedited appeal if discontinuation poses health risks.

Clinician Corner: Medical Necessity Letter

When crafting appeals or initial PA requests, include these evidence-backed elements:

Essential Components

  • Clinical presentation: Specific TED symptoms, CAS score, proptosis measurements, impact on vision/quality of life
  • Prior treatments: Dates, doses, duration of corticosteroids; response or reasons for discontinuation
  • Literature support: FDA labeling, ATA guidelines, peer-reviewed studies demonstrating Tepezza efficacy
  • Monitoring plan: Glucose monitoring (especially in diabetes), hearing assessments, infusion reaction protocols

Key References to Cite

  • FDA Tepezza prescribing information
  • American Thyroid Association guidelines for TED management
  • Clinical studies demonstrating superior efficacy vs. placebo in moderate-to-severe TED

About Counterforce Health: We help patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance policies and appeal processes can change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For assistance with appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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