By Counterforce Health Team in Tepezza (teprotumumab) —

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

Answer Box: Getting Tepezza Covered by Humana in Pennsylvania

Tepezza (teprotumumab) requires prior authorization from Humana for thyroid eye disease (TED) treatment. To get approved: (1) Your ophthalmologist or endocrinologist must document active, moderate-to-severe TED with Clinical Activity Score ≥3 and proptosis measurements, (2) Submit prior authorization through Humana's provider portal with medical necessity letter and clinical documentation, (3) If denied, you have 65 days to appeal through Medicare's process (not Pennsylvania's state external review, which doesn't apply to Medicare Advantage plans). Start today: Call the number on your Humana ID card to verify your plan's specific requirements and get the PA form.

Table of Contents

Humana's Coverage Policy Overview

Humana covers Tepezza as a Medicare Part B drug under most Medicare Advantage plans in Pennsylvania, but prior authorization is required for all members. The drug is billed using HCPCS code J3241 (10 mg per unit) and must be administered in approved clinical settings.

Plan Types and Requirements

  • Medicare Advantage (Part C): Most common Humana plan type in Pennsylvania; follows Medicare guidelines with additional Humana-specific criteria
  • Medicare Part D: Some standalone prescription plans may cover Tepezza, though it's typically processed under Part B
  • Commercial Plans: Less common but may have different criteria than Medicare plans
Note: Pennsylvania's state external review program does not apply to Medicare Advantage plans. Medicare appeals follow federal timelines and procedures.

Where to Find Official Documentation

Medical Necessity Requirements

Humana typically requires documentation of the following criteria for Tepezza approval:

Clinical Documentation Required

Requirement Specific Criteria Documentation Needed
TED Diagnosis Active, moderate-to-severe thyroid eye disease Clinical notes, exam findings
Clinical Activity Score CAS ≥3 out of 7 Standardized CAS assessment
Proptosis Measurement ≥3mm above normal or ≥2mm increase Hertel/Luedde exophthalmometer readings
Thyroid Status Euthyroid or controlled hyperthyroidism Recent TSH, free T4, free T3 labs
Prescriber Qualification Ophthalmology, endocrinology, or neuro-ophthalmology Provider credentials
Prior Treatments Documentation of corticosteroid trial or contraindication Treatment history, outcomes

FDA-Approved Indications

Tepezza is FDA-approved for thyroid eye disease regardless of activity or duration. However, most insurance plans, including Humana, still require evidence of active disease for coverage approval.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who: Patient or clinic staff
Action: Call Humana customer service (number on ID card) to confirm:

  • Prior authorization requirements for your specific plan
  • Preferred infusion sites in Pennsylvania
  • Current formulary status

2. Gather Clinical Documentation

Who: Healthcare provider
Required documents:

  • Complete medical history and TED diagnosis
  • Clinical Activity Score assessment
  • Proptosis measurements using validated tools
  • Recent thyroid function tests
  • Documentation of prior treatment attempts

3. Complete Prior Authorization

Who: Prescribing physician
Submit through: Humana provider portal
Timeline: Allow 7-14 business days for standard review

4. Schedule Infusions (if approved)

Who: Patient and clinic
Billing code: J3241 (teprotumumab-trbw, 10 mg per unit)
Course: 8 infusions over 21 weeks (initial 10 mg/kg, then 20 mg/kg every 3 weeks)

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
Insufficient clinical documentation Submit complete CAS assessment and proptosis measurements CAS scoring guide
Step therapy not met Document corticosteroid contraindication or failure Medical records showing adverse reactions or ineffectiveness
Non-specialist prescriber Transfer care or obtain co-signature Ophthalmology or endocrinology consultation
Coding errors Verify J3241 units calculation Tepezza billing guide

Appeals Process for Pennsylvania Residents

Important: Medicare vs. State Appeals

For Humana Medicare Advantage plans: You must use the federal Medicare appeals process, not Pennsylvania's state external review program. Pennsylvania's Independent External Review Program only applies to commercial insurance and ACA marketplace plans.

Medicare Appeals Timeline

  1. Reconsideration (Level 1)
    • Deadline: 65 days from denial notice
    • Decision timeline: 7 days for Part D drugs (72 hours if expedited)
    • How to file: Through MyHumana portal or by mail
  2. Independent Review Entity (Level 2)
    • Automatic: If Level 1 upholds denial
    • Decision timeline: 7 days standard (72 hours expedited)
    • Reviewer: Medicare-contracted independent entity
  3. Administrative Law Judge (Level 3)
    • Threshold: If drug cost meets annual threshold (verify current amount)
    • Timeline: 90 days for decision

Required Appeal Documents

  • Original denial letter
  • Medical necessity letter from prescriber
  • Complete medical records supporting TED diagnosis
  • Evidence of prior treatment failures or contraindications
  • Updated clinical assessments if disease has progressed
Tip: Request expedited appeals if your condition is urgent or rapidly progressing. Include a physician statement about the urgency.

Clinician Corner: Medical Necessity Letter

Essential Components for Tepezza Letters

When writing a medical necessity letter for Tepezza, include these key elements:

Patient Information:

  • Demographics and insurance details
  • Primary TED diagnosis with ICD-10 codes
  • Duration and progression of symptoms

Clinical Justification:

  • Current Clinical Activity Score with specific findings
  • Proptosis measurements (baseline and current)
  • Impact on vision, daily activities, and quality of life
  • Thyroid status and management

Treatment History:

  • Previous therapies attempted (corticosteroids, other treatments)
  • Reasons for discontinuation (ineffectiveness, side effects, contraindications)
  • Why Tepezza is the most appropriate next step

Supporting Evidence:

  • Reference to FDA labeling for TED indication
  • Cite relevant clinical guidelines or studies
  • Include photos or imaging if available

Sample Template Language

"[Patient name] has active, moderate-to-severe thyroid eye disease with a Clinical Activity Score of [X]/7, including [specific findings]. Current proptosis measurements are [X]mm OD and [X]mm OS, representing a [X]mm increase from baseline. Previous treatment with [corticosteroids/other] resulted in [outcome]. Based on FDA approval for TED and clinical guidelines, Tepezza represents the most appropriate therapy to prevent irreversible orbital changes and preserve vision."

Download the official medical necessity template from the manufacturer.

Costs and Financial Assistance

Expected Costs

  • Drug cost: Approximately $17,511 per 500mg vial (March 2025 pricing)
  • Full course: $350,000-$500,000+ depending on patient weight and wastage
  • Medicare coverage: Typically 80% under Part B after deductible

Financial Assistance Options

  1. Amgen By Your Side: Manufacturer support program
    • Copay assistance for eligible patients
    • Prior authorization support
    • Apply online or call 1-833-TEPEZZA
  2. Medicare Extra Help: Low-income subsidy program
  3. State Pharmaceutical Assistance Programs

Frequently Asked Questions

How long does Humana prior authorization take in Pennsylvania? Standard prior authorization decisions are typically made within 7-14 business days. Expedited reviews (for urgent medical situations) can be completed within 72 hours if clinical urgency is documented.

What if Tepezza is non-formulary on my plan? You can request a formulary exception through Humana's exception process. Your doctor will need to demonstrate medical necessity and explain why formulary alternatives are inappropriate.

Can I get an expedited appeal if my TED is worsening? Yes, Medicare allows expedited appeals for urgent medical situations. Your doctor must provide documentation that standard timelines could jeopardize your health.

Does smoking affect Tepezza coverage? Some insurers require smoking cessation counseling or documentation of non-smoking status, as smoking can worsen TED outcomes. Check your specific plan requirements.

What happens if I move from Pennsylvania during treatment? Your Humana Medicare Advantage coverage may change based on plan availability in your new location. Contact Humana during your move to ensure continuity of care.

Can I appeal if I'm denied due to insufficient documentation? Yes, you can submit additional clinical documentation during the appeals process. Work with your healthcare provider to gather any missing information before resubmitting.

From Our Advocates

In our experience helping patients navigate complex specialty drug approvals, we've found that the most successful Tepezza authorizations include comprehensive clinical documentation from the start. One approach that works well is having the ophthalmology and endocrinology teams coordinate their documentation, ensuring both the eye-specific findings (CAS, proptosis) and thyroid management are clearly presented. This collaborative approach often prevents the back-and-forth requests for additional information that can delay approval by weeks.

Getting Help with Your Appeal

If you're struggling with a Humana denial in Pennsylvania, Counterforce Health specializes in turning insurance denials into successful appeals. Our platform analyzes your specific denial reason, identifies the gaps in your initial submission, and helps draft evidence-backed appeals that address your plan's exact criteria. We work with patients, clinicians, and specialty pharmacies to streamline the prior authorization process and reduce the time between denial and approval.

Whether you need help understanding Humana's specific requirements for Tepezza or crafting a compelling medical necessity argument, having expert support can make the difference between months of delays and getting your treatment approved quickly.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies can change, and individual circumstances vary. Always consult with your healthcare provider and insurance plan for the most current requirements and procedures.

Need Help? Contact the Pennsylvania Insurance Department's consumer services at pa.gov for general insurance questions, or Medicare at 1-800-MEDICARE for Medicare Advantage appeals guidance.

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