By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Humana in Ohio: Complete Guide to Forms, Appeals & Approval

Answer Box: Getting Tepezza Covered by Humana in Ohio

Tepezza (teprotumumab) requires prior authorization from Humana in Ohio for all plan types—Medicare Advantage, Medicaid (Humana Healthy Horizons), and commercial plans. The fastest path to approval: 1) Your prescriber submits a PA request via CoverMyMeds or fax to 877-486-2621 with clinical documentation proving thyroid eye disease diagnosis and medical necessity, 2) If denied, file an internal appeal within 65 days (Medicare) or per your plan's timeline, 3) Request external review through the Ohio Department of Insurance within 180 days if the internal appeal fails.

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Required Forms for Tepezza Prior Authorization
  3. Submission Portals & Online Options
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Coordination
  6. Member & Provider Support Lines
  7. Ohio Appeals & External Review Process
  8. Common Denial Reasons & Solutions
  9. When to Contact Ohio Regulators

Start Here: Verify Your Plan & Find Forms

Before requesting Tepezza coverage, confirm your specific Humana plan type, as requirements vary:

Tip: Your member ID card indicates plan type. Medicare Advantage cards show "Medicare" prominently, while Medicaid cards display "Medicaid" or "Healthy Horizons."

Required Forms for Tepezza Prior Authorization

Medicare Advantage & Commercial Plans

Download the Prior Authorization for Professionally Administered Drugs form from Humana's provider portal. This form requires:

  • Patient demographics and insurance information
  • Prescriber details (NPI, contact information)
  • Drug specifics: Tepezza (teprotumumab), HCPCS code J3241, dosing schedule
  • Clinical documentation: thyroid eye disease diagnosis, severity assessment, prior treatments
  • Site of care (infusion center, hospital outpatient, home infusion)

Ohio Medicaid (Humana Healthy Horizons)

For Medicaid members, contact the Humana National Transplant Network at 866-421-5663 for the appropriate form, or email [email protected]. The request must include the HCPCS code J3241 and corresponding NDC when billing.

Submission Portals & Online Options

Electronic Submission (Preferred)

CoverMyMeds: Humana's preferred platform for electronic prior authorizations. Prescribers can:

  1. Log into CoverMyMeds
  2. Select "Humana" as the payer
  3. Enter patient and drug information
  4. Upload supporting clinical documentation
  5. Submit electronically for faster processing

Availity: Alternative platform for medical prior authorizations. Register at Availity.com with your NPI and practice information.

Provider Portals

  • Humana Provider Portal: Access prior authorization tools at provider.humana.com
  • CenterWell Specialty Pharmacy: For specialty drug coordination (verify current link with Humana)

Fax Numbers & Mailing Addresses

Primary Fax Numbers

  • Specialty Drug Prior Authorization: 877-486-2621
  • CenterWell Specialty Pharmacy: 877-405-7940
  • Ohio Medicaid Specialty Drugs: 502-508-9300

Cover Sheet Requirements

Include on all fax submissions:

  • Patient's full name, date of birth, and member ID
  • Prescriber name, NPI number, and contact information
  • Drug name (Tepezza/teprotumumab), dose, and frequency
  • "URGENT: Prior Authorization Request" if time-sensitive
  • Page count and date of submission
Note: Incomplete cover sheets can delay processing by 3-5 business days.

Specialty Pharmacy Coordination

Tepezza requires coordination with Humana's specialty pharmacy network due to its complex administration and high cost.

Transfer Instructions

  1. New Prescriptions: Prescriber sends directly to CenterWell Specialty Pharmacy via e-prescribing or fax to 877-405-7940
  2. Existing Prescriptions: Member initiates transfer through CenterWell mobile app or online portal
  3. Required Documentation:
    • Front and back of insurance cards
    • Prior authorization approval
    • Infusion site preferences
    • Clinical notes supporting medical necessity

Onboarding Process

CenterWell will:

  • Verify insurance coverage and benefits
  • Coordinate prior authorization if not completed
  • Arrange infusion scheduling (home or facility-based)
  • Provide patient education and consent forms
  • Connect with manufacturer support programs

Member & Provider Support Lines

For Members

  • General Member Services: Number on back of member ID card
  • Pharmacy Questions: 1-866-488-5995 (Medicare members)
  • Case Management: 866-421-5663 (National Transplant Network for specialty drugs)

For Providers

  • Prior Authorization Support: 800-555-CLIN (2546)
  • Specialty Drug Coordination: 866-421-5663
  • Technical Portal Issues: Contact through provider portal help desk

What to Ask When Calling

  • "What specific clinical criteria does Tepezza need to meet for approval?"
  • "Can you provide the exact prior authorization form for my patient's plan type?"
  • "What's the current processing timeline for Tepezza requests?"
  • "Is step therapy required, and what alternatives must be tried first?"

Ohio Appeals & External Review Process

If Humana denies your Tepezza request, Ohio provides multiple appeal levels.

Internal Appeals

Timeline: 65 days from denial notice (Medicare); varies for commercial plans How to Submit:

  • Online through Humana member portal
  • Fax appeals to number provided in denial letter
  • Mail to address specified in denial notice

Required Documents:

  • Original denial letter
  • Additional clinical documentation
  • Prescriber's medical necessity letter
  • Any new supporting evidence

External Review (Ohio Department of Insurance)

If internal appeals fail, Ohio residents can request external review within 180 days of the final denial.

Process:

  1. File request with your health plan (they notify Ohio DOI)
  2. Independent Review Organization (IRO) assigned
  3. Submit additional evidence if available
  4. Decision within 30 days (standard) or 72 hours (expedited)
  5. IRO decision is binding on the insurer

Contact: Ohio Department of Insurance Consumer Hotline: 1-800-686-1526

Important: Self-funded employer plans follow federal ERISA rules, not Ohio's external review process.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient clinical documentation Submit comprehensive medical necessity letter Diagnosis confirmation, CAS scores, proptosis measurements, photos
Step therapy not completed Request step therapy exception Documentation of contraindications to steroids or prior failures
Non-formulary drug File formulary exception Comparative effectiveness data, alternative drug failures
Coding errors Correct billing codes Use HCPCS J3241 with appropriate NDC
Pregnancy concerns Provide safety assessment Pregnancy test results, contraception plan, risk-benefit analysis

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Diagnosis: Thyroid eye disease with ICD-10 code
  • Severity: Clinical Activity Score (CAS), proptosis measurements, functional impact
  • Prior treatments: Steroids tried and outcomes, contraindications to alternatives
  • Clinical rationale: Why Tepezza is medically necessary vs. other options
  • Monitoring plan: Safety assessments, follow-up schedule
  • Guidelines: Reference FDA labeling and ophthalmology society recommendations

When to Contact Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Humana improperly denies external review eligibility
  • Appeal deadlines are not communicated clearly
  • You suspect bad faith denial practices
  • The insurer fails to follow Ohio insurance laws

Ohio Department of Insurance Consumer Services: 1-800-686-1526

UHCAN Ohio (Universal Health Care Action Network) provides consumer advocacy and can help navigate complex appeals.

From Our Advocates

"We've seen Tepezza approvals succeed when prescribers include detailed photos showing proptosis progression, specific CAS scores at multiple time points, and clear documentation of steroid contraindications or failures. The key is painting a complete clinical picture that demonstrates both medical necessity and the inadequacy of alternatives. Don't assume the reviewer knows thyroid eye disease—explain why Tepezza's mechanism is uniquely suited to your patient's condition."

Coverage Support Resources

Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify specific coverage criteria, then drafts point-by-point rebuttals using the right medical evidence and payer-specific requirements. For complex cases like Tepezza, where denials often hinge on inadequate clinical documentation or step therapy requirements, having expert appeal support can significantly improve approval odds.

Manufacturer Support: Amgen offers the "Amgen By Your Side" program providing benefits verification, prior authorization assistance, and financial support for eligible patients. Contact through tepezzahcp.com or your prescriber.

Frequently Asked Questions

How long does Humana take to process Tepezza prior authorization in Ohio? Standard processing is 7-14 business days. Expedited requests (for urgent medical situations) are processed within 72 hours.

What if Tepezza isn't on my Humana formulary? Request a formulary exception through your prescriber. Include documentation showing medical necessity and why formulary alternatives are inadequate.

Can I appeal if I've moved to Ohio from another state? Yes, but you'll need to establish Ohio residency and follow Ohio's external review process for state-regulated plans.

Does step therapy apply if I tried steroids years ago? Document prior steroid use with dates, doses, outcomes, and reasons for discontinuation. Recent trials may be required depending on plan policy.

What's the difference between Medicare and Medicaid coverage for Tepezza in Ohio? Medicare Advantage follows federal Part B rules, while Ohio Medicaid has state-specific prior authorization requirements managed through Humana's National Transplant Network.

Update Frequency

Insurance policies, forms, and contact information change regularly. Re-check these resources:

  • Monthly: Fax numbers and portal links
  • Quarterly: Prior authorization forms and requirements
  • Annually: Formulary placement and step therapy protocols

For the most current information, always verify details directly with Humana's provider portal or member services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly. For assistance with complex appeals, consider working with organizations like Counterforce Health that specialize in insurance coverage advocacy.

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