By Counterforce Health Team in Tepezza (teprotumumab) —

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

Quick Answer: Getting Tepezza Covered by Humana in Michigan

Tepezza (teprotumumab) requires prior authorization from Humana for thyroid eye disease treatment. Your fastest path to approval: (1) Confirm your ophthalmologist is in-network and has documented TED diagnosis with CAS ≥4, (2) Submit the prior authorization request through CoverMyMeds or Humana's provider portal with complete clinical documentation, and (3) If denied, file an internal appeal within 65 days, followed by external review through Michigan DIFS within 127 days. Start by checking Humana's current prior authorization requirements.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Understanding Timelines
  7. If You Need to Provide Additional Information
  8. If Your Request is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps Michigan patients and their healthcare providers navigate Humana's prior authorization process for Tepezza (teprotumumab), a specialty medication for thyroid eye disease (TED). Whether you have Humana Medicare Advantage, Medicaid, or commercial coverage, we'll walk you through the exact steps, required documentation, and appeals process specific to Michigan.

Who this helps:

  • Patients diagnosed with thyroid eye disease needing Tepezza
  • Healthcare providers submitting prior authorizations
  • Caregivers advocating for coverage approval
From our advocates: "The most successful Tepezza approvals we see include comprehensive ophthalmology documentation with clear CAS scores, recent thyroid labs, and detailed prior therapy records. When providers submit complete packets upfront, approval rates increase significantly compared to incomplete initial submissions."

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Humana offers several plan types in Michigan, each with different prior authorization processes:

  • Medicare Advantage: Coverage follows Part B rules for infusions
  • Commercial Plans: Varies by employer group
  • Medicaid (Humana Healthy Horizons): State-specific requirements

Step 2: Check Network Status

Ensure your prescribing ophthalmologist is in Humana's network. Out-of-network providers face additional hurdles and may require exceptions.

Step 3: Verify Tepezza's Formulary Status

Tepezza appears on Humana's 2024 Preauthorization List, requiring prior authorization regardless of plan type. The medication is billed under HCPCS code J3241.

Gather Required Documentation

Clinical Documentation Requirements

Essential Records:

  • Confirmed TED diagnosis with ICD-10 codes
  • Clinical Activity Score (CAS) ≥4 documented by ophthalmologist
  • Proptosis measurements in millimeters (exophthalmometry)
  • Recent thyroid function tests (within 30 days)
  • Documentation of euthyroid status or values within 50% of reference range

Prior Therapy Documentation:

  • Record of previous treatments (corticosteroids, radiation, surgery)
  • Reasons for discontinuation or failure
  • Contraindications to alternative therapies

Administrative Requirements

  • Patient demographics and Humana member ID
  • Prescribing provider NPI and specialty designation
  • Site of care information
  • Weight-based dosing calculations
Tip: Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing plan policies and drafting evidence-backed rebuttals. Their platform can help identify exactly what documentation Humana requires for Tepezza approvals.

Submit Your Prior Authorization Request

Submission Methods

Preferred Method: Electronic Submission

Alternative Methods:

  • Fax to Humana Clinical Pharmacy Review (verify current fax number)
  • Mail to address on prior authorization form

Required Forms

Access the most current prior authorization forms through:

Clean Request Packet Checklist

  • Completed prior authorization form
  • Clinical notes with TED diagnosis
  • CAS score documentation
  • Proptosis measurements
  • Thyroid function tests (≤30 days old)
  • Prior therapy records
  • Prescriber attestation letter
  • Patient demographics and insurance information

Follow-Up and Tracking

When to Follow Up

  • Initial submission: 3-5 business days
  • Standard review: 7-14 business days
  • Expedited review: 72 hours

What to Ask During Follow-Up Calls

  1. "What's the reference number for my prior authorization request?"
  2. "Has all required documentation been received?"
  3. "What's the expected decision timeline?"
  4. "Are any additional documents needed?"

Documentation

Keep detailed records of all communications, including:

  • Date and time of calls
  • Representative names
  • Reference numbers
  • Next steps discussed

Understanding Timelines

Humana Decision Timelines

Request Type Standard Timeline Expedited Timeline
Pre-service 30 calendar days 72 hours
Post-service 60 calendar days N/A
Part D appeals 7 days standard 72 hours expedited

Source: Humana Member Appeals Process

Michigan-Specific Considerations

Michigan's external review process provides additional protection with 127 days to file after final internal denial, managed by the Michigan Department of Insurance and Financial Services.

If You Need to Provide Additional Information

Common Information Requests

Medical Necessity Clarifications:

  • Additional clinical rationale
  • Specialist consultation notes
  • Updated lab values
  • Treatment response documentation

Administrative Clarifications:

  • Corrected diagnosis codes
  • Updated provider information
  • Site of care verification

Response Strategy

When Humana requests additional information:

  1. Respond within the specified timeframe (usually 14 days)
  2. Address each question specifically
  3. Include supporting literature when appropriate
  4. Maintain professional, clinical language

If Your Request is Denied

Internal Appeal Process

Timeline: 65 days from denial notice to file appeal

How to File:

  • Online through MyHumana
  • Phone: Number on member ID card
  • Written request with supporting documentation

Required Documentation:

  • Original denial letter
  • Clinical evidence supporting medical necessity
  • Prescriber's medical necessity letter
  • Any new supporting literature

External Review in Michigan

If your internal appeal is denied, Michigan law provides external review rights:

Timeline: 127 days from final internal denial Process: File with Michigan DIFS Decision Timeline: 60 days standard, 72 hours expedited Outcome: Binding decision on Humana

Note: Michigan's 127-day external review window is longer than the federal 120-day standard, providing additional time for patients to gather documentation.

Renewal and Re-Authorization

When to Resubmit

  • Annual plan renewals: January 1st for most plans
  • Benefit year changes: When switching plans
  • Treatment course completion: After 8-infusion series

Documentation for Renewal

  • Updated clinical assessment
  • Treatment response documentation
  • Current thyroid function tests
  • Continued medical necessity justification

Quick Reference Checklist

Before Submitting:

  • Verify in-network ophthalmologist
  • Confirm TED diagnosis with CAS ≥4
  • Obtain recent thyroid labs (≤30 days)
  • Document prior therapy failures
  • Complete Humana PA form

After Submission:

  • Track reference number
  • Follow up in 3-5 business days
  • Prepare for potential information requests
  • Know appeal deadlines (65 days internal, 127 days external)

If Denied:

  • File internal appeal within 65 days
  • Gather additional clinical evidence
  • Consider peer-to-peer review
  • File Michigan external review if needed

Frequently Asked Questions

How long does Humana prior authorization take for Tepezza in Michigan? Standard reviews take 7-14 business days, with expedited reviews completed within 72 hours when medical urgency is documented.

What if Tepezza isn't on my Humana formulary? Request a formulary exception with comprehensive medical necessity documentation. Counterforce Health can help identify the specific criteria your plan requires for non-formulary coverage.

Can I request an expedited appeal in Michigan? Yes, both Humana internal appeals and Michigan external reviews offer expedited options when delays would jeopardize patient health.

Does step therapy apply to Tepezza coverage? Many Humana plans require documentation of prior corticosteroid therapy or contraindications before approving Tepezza.

What's the cost of Tepezza if approved? With Humana coverage, patient costs depend on plan design. The full course can exceed $400,000, making prior authorization essential.

Who can help if I'm struggling with the appeals process? Michigan DIFS offers consumer assistance at 877-999-6442, and external review coordination for denied appeals.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current insurance requirements directly with Humana. Coverage policies and procedures may change without notice.

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