By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Humana in Illinois: PA Forms, Appeals, and Approval Guide

Answer Box: Getting Tepezza Covered by Humana in Illinois

Tepezza (teprotumumab) requires prior authorization from Humana and is typically covered under Medicare Part B as a medical benefit, not Part D. The fastest path to approval: (1) Have your ophthalmologist or endocrinologist submit a PA request with documented thyroid eye disease diagnosis, Clinical Activity Score ≥3, euthyroid status labs, and prior treatment history to Humana's professionally administered drug team at 1-888-447-3430, (2) Ensure billing uses HCPCS code J3241, and (3) If denied, file an internal appeal within 65 days, then request Illinois external review within 30 days of final denial through the Illinois Department of Insurance.

Table of Contents

Humana Plan Types & Coverage Implications

Understanding your specific Humana plan type is crucial for Tepezza coverage, as the approval pathway differs significantly between Medicare Advantage and commercial plans.

Medicare Advantage (Part C): Most Humana members in Illinois have Medicare Advantage plans. Tepezza is covered under the medical benefit (Part B), not the prescription drug benefit (Part D). This means it's administered in a clinical setting and billed using HCPCS code J3241 rather than dispensed at a retail pharmacy.

Medicare Part D: Tepezza is generally not found on standard Humana Part D formularies because it requires professional administration. If you see Tepezza listed as "not covered" on your Part D drug list, this is expected—you need Part B coverage instead.

Commercial Plans: For employer-sponsored or individual Humana plans, Tepezza typically requires prior authorization and may have step therapy requirements depending on your specific policy.

Note: Humana's Medicare Advantage prior authorization denial rate is approximately 3.5% (2023)—among the lowest of major insurers—but denials often stem from incomplete documentation rather than medical necessity.

Tepezza Formulary Status & Tier Placement

Part B Medical Benefit: Tepezza is not assigned a traditional formulary "tier" because it's covered as a Medicare Part B professionally administered drug rather than a Part D pharmacy benefit. Coverage follows Medicare guidelines with Humana-specific prior authorization requirements.

Prior Authorization Required: All Humana plans require prior authorization for Tepezza. The medication cannot be administered without pre-approval, regardless of your plan type.

No Step Therapy for FDA-Approved Indication: Unlike some specialty medications, Tepezza typically doesn't require step therapy when used for its FDA-approved indication (thyroid eye disease), though documentation of disease severity and specialist involvement is mandatory.

Prior Authorization Requirements

Humana requires comprehensive clinical documentation to approve Tepezza for thyroid eye disease. Here's what your provider must submit:

Coverage at a Glance

Requirement What It Means Where to Find It Source
Specialist Prescriber Ophthalmologist or endocrinologist Provider credentials Humana PA Requirements
TED Diagnosis Active, moderate-to-severe thyroid eye disease Clinical notes, CAS score FDA Tepezza Label
Clinical Activity Score CAS ≥3 or equivalent severity markers Ophthalmology assessment Humana Clinical Policy
Euthyroid Status Free T3/T4 within 50% of normal limits Recent lab results Humana PA Form Requirements
Prior Treatment History Documentation of previous therapies Medical records Humana Clinical Criteria

Required Documentation Checklist

✓ Diagnosis Confirmation:

  • Documented thyroid eye disease with Clinical Activity Score ≥3
  • Supporting clinical photographs or measurements
  • Proptosis measurements if applicable

✓ Laboratory Evidence:

  • Recent Free T3 and Free T4 levels
  • Thyroid function within acceptable ranges (euthyroid status)
  • TSH levels if relevant to clinical picture

✓ Provider Qualifications:

  • Prescription from ophthalmologist or endocrinologist
  • Specialist consultation notes if prescribed by primary care

✓ Treatment History:

  • Previous therapies attempted (steroids, other immunosuppressants)
  • Reasons for discontinuation or failure
  • Contraindications to conventional treatments if applicable

Specialty Pharmacy Network

CenterWell Specialty Pharmacy is Humana's primary specialty pharmacy partner for Tepezza in Illinois. However, since Tepezza is administered in clinical settings rather than self-administered, the specialty pharmacy primarily handles coordination and delivery to the infusion center.

Key Contact Information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Hours: Monday–Friday 8 a.m.–8 p.m., Saturday 8 a.m.–6 p.m. Central Time
  • Fax for Prescriptions: 1-877-405-7940

Process Overview:

  1. Provider submits prior authorization to Humana
  2. Once approved, prescription is sent to CenterWell
  3. CenterWell coordinates delivery to your infusion center
  4. Clinical staff administers Tepezza per FDA-approved protocol
Tip: Using out-of-network specialty pharmacies will result in full out-of-pocket costs. Always verify your infusion center works with CenterWell before scheduling treatments.

Cost-Share Basics

Understanding your financial responsibility helps you plan for Tepezza treatment costs, which can exceed $400,000 for a full course.

Medicare Part B Coverage:

  • Medicare pays 80% of the Medicare-approved amount
  • You pay 20% coinsurance after meeting your Part B deductible
  • Medigap insurance may cover your 20% coinsurance

Manufacturer Support:

  • Amgen By Your Side offers copay assistance programs
  • Income and insurance type restrictions may apply
  • Contact: amgenbyyourside.com

Foundation Grants:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Income-based eligibility requirements
Note: This information is educational only. Consult your benefits summary and Humana member services for your specific cost-sharing amounts.

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Provider)

  • Complete medical records from ophthalmologist or endocrinologist
  • Recent thyroid function tests (Free T3, Free T4)
  • Clinical photographs or measurements supporting TED diagnosis
  • Timeline: 1-2 business days

2. Complete Humana PA Form (Provider)

  • Use Humana's professionally administered drug prior authorization form
  • Include all required clinical documentation
  • Submit via: Fax to 1-888-447-3430 or Humana provider portal
  • Timeline: Same day submission possible

3. Humana Review Process

  • Standard review: 15 business days for Part B requests
  • Expedited review available for urgent cases
  • Timeline: 1-15 business days depending on request type

4. Approval Notification (Provider/Patient)

  • Provider receives approval notification
  • Patient can schedule first infusion
  • Timeline: 1-2 business days after approval

5. CenterWell Coordination (Automatic)

  • Specialty pharmacy coordinates drug delivery to infusion center
  • Clinical staff receives administration instructions
  • Timeline: 3-5 business days

6. Treatment Initiation (Patient)

  • First infusion scheduled at approved facility
  • Billing processed under Medicare Part B using J3241
  • Timeline: 1-2 weeks after approval

7. Ongoing Monitoring (Provider/Patient)

  • Document treatment response for potential reauthorization
  • Monitor for adverse effects per FDA guidelines
  • Timeline: Throughout 8-infusion course

Required Forms and Portals

Provider Submission:

  • Humana Provider Portal (verify current link)
  • Fax: 1-888-447-3430 for professionally administered drugs
  • Phone: Available through provider services line

Patient Tracking:

  • Humana member portal for approval status
  • CenterWell patient portal for delivery coordination

Common Approval Patterns

Based on successful Tepezza approvals through Humana, strong submissions typically include:

Clinical Documentation Excellence:

  • Detailed ophthalmology consultation notes with specific TED severity markers
  • High-quality clinical photographs showing orbital changes
  • Quantified proptosis measurements when applicable
  • Clear documentation of functional impairment

Laboratory Completeness:

  • Recent thyroid function tests (within 30-90 days)
  • Results showing euthyroid status or controlled hyperthyroidism
  • Historical thyroid levels if relevant to TED development

Treatment Rationale:

  • Clear explanation of TED activity and severity
  • Specialist recommendation for Tepezza over alternatives
  • Discussion of expected outcomes and monitoring plan
From Our Advocates: We've seen cases where initial denials were overturned simply by adding clinical photographs and quantified severity measurements to the resubmission. Visual documentation of orbital changes can be particularly compelling for reviewers unfamiliar with TED presentations.

Appeals Process in Illinois

If Humana denies your Tepezza prior authorization, Illinois provides strong patient protection through multiple appeal levels.

Internal Appeal (First Step)

Timeline: File within 65 days of denial notice Humana Decision: 7 days for Part D, 30 days for Part C pre-service How to File:

  • Online through Humana member portal
  • Phone: Customer service number on your ID card
  • Mail: Address provided in denial letter

Required Information:

  • Member name and ID number
  • Claim or service number from denial
  • Detailed reason for disagreement
  • Additional supporting documentation

External Review (Illinois Department of Insurance)

If Humana denies your internal appeal, Illinois law guarantees independent external review.

Timeline: Request within 30 days of final internal denial Review Decision: 5 business days after IRO receives materials Cost: Free to consumers (insurers pay review costs)

How to Request:

  • Contact Illinois Department of Insurance: (877) 527-9431
  • Submit request using DOI external review forms
  • Provide all denial letters and medical documentation

Independent Review Process:

  • Board-certified physician with relevant expertise reviews your case
  • Reviewer has no financial relationship with Humana
  • Decision is binding on the insurance company

Illinois-Specific Resources

Illinois Department of Insurance Office of Consumer Health Insurance (OCHI):

  • Phone: (877) 527-9431
  • Assists with appeals and external review requests
  • Can intervene informally with insurers

Illinois Attorney General Health Care Bureau:

  • Helpline: (877) 305-5145
  • Provides consumer assistance with health insurance problems
  • Can facilitate informal resolution discussions
Note: Illinois' 30-day external review deadline is shorter than many states' 4-month window. Don't delay if you plan to request external review.

FAQ

How long does Humana prior authorization take for Tepezza in Illinois? Standard PA review takes up to 15 business days for Part B medications. Expedited review (for urgent medical situations) can be completed within 24-72 hours. Submit complete documentation to avoid delays.

What if Tepezza is listed as non-formulary on my Part D plan? This is expected. Tepezza is covered under Medicare Part B (medical benefit) rather than Part D (prescription benefit) because it requires professional administration. Check your Part B coverage instead.

Can I request an expedited appeal if Humana denies Tepezza? Yes. If delaying treatment would seriously jeopardize your health, request expedited review. Provide documentation from your physician explaining the medical urgency.

Does step therapy apply if I haven't tried steroids first? Humana's current policy may require documentation of previous treatments or contraindications to conventional therapy. Your specialist should address this in the PA submission.

What happens if my weight changes during the 8-infusion course? Tepezza dosing is weight-based (20 mg/kg for infusions 2-8). Significant weight changes may require reauthorization for adjusted dosing. Discuss with your provider.

How do I find an in-network infusion center in Illinois? Use Humana's provider directory at findcare.humana.com to locate in-network infusion centers. Verify the facility can work with CenterWell Specialty Pharmacy.

What if I have both Humana Medicare Advantage and a supplement plan? Your Medicare Advantage plan handles the PA approval process. Your supplement insurance may help with the 20% coinsurance after Medicare pays its portion.

Can I appeal to Illinois state regulators if external review fails? External review decisions are generally final and binding. However, you can file complaints about insurance company conduct with the Illinois Department of Insurance if you believe procedural errors occurred.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approvals by turning denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned with each payer's requirements. For medications like Tepezza, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals with the required clinical facts and operational details payers expect. Learn more at counterforcehealth.org.

When dealing with high-cost specialty medications like Tepezza, having expert guidance can make the difference between approval and denial. Counterforce Health specializes in creating compelling medical necessity arguments that address payer-specific requirements while tracking deadlines and procedural requirements across different insurance types.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and should not be considered medical advice. Insurance coverage varies by plan and individual circumstances. Always consult your healthcare provider for medical decisions and verify current coverage details with Humana directly. Policy requirements and forms may change; confirm current information through official sources before submitting requests.

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