By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by Humana in Washington: Forms, Appeals, and Approval Strategies

Answer Box: Your Fastest Path to Tepezza Coverage

Tepezza (teprotumumab) requires prior authorization from Humana Medicare Advantage plans in Washington. Your ophthalmologist must document moderate-to-severe active thyroid eye disease (CAS ≥3) and submit clinical evidence through Humana's medical benefit system using J3241 billing code.

Three steps to start today:

  1. Contact your ophthalmologist to initiate prior authorization via Humana's provider portal or fax 1-877-486-2621
  2. Gather documentation: CAS score, proptosis measurements, photos, and failed steroid therapy records
  3. If denied, file internal appeal within 60 days—Washington residents can then request external review through the Office of the Insurance Commissioner

Expected timeline: 30 days for initial determination, 7 days for expedited appeals.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Tepezza Formulary Status & Billing
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Coordination
  5. Cost-Share Basics
  6. Submission Process & Forms
  7. Common Approval Patterns
  8. Appeals Playbook for Washington
  9. When to Escalate
  10. FAQ

Plan Types & Coverage Implications

Humana Medicare Advantage plans dominate Washington's senior market, with different structures affecting your Tepezza access:

  • HMO plans: Require referrals to ophthalmology specialists—essential since Humana mandates specialist management for TED
  • PPO plans: Allow direct specialist access but may have higher out-of-network costs for infusion centers
  • Original Medicare + Humana Part D: Tepezza is covered under Part B (medical), not Part D (pharmacy)
Note: Tepezza infusions are always billed as Part B medical benefits using J3241, regardless of your plan type. Your Humana Medicare Advantage plan processes these as medical claims, not pharmacy benefits.

Network considerations matter significantly in Washington, where major infusion centers like Seattle Cancer Care Alliance and Virginia Mason must be in-network to minimize your costs.

Tepezza Formulary Status & Billing

Coverage Classification

Tepezza is covered under Medicare Part B medical benefits, not Part D pharmacy formularies. This means:

Coverage Type Applies to Tepezza? Billing Code Patient Responsibility
Part B Medical ✓ Yes J3241 (per 1 mg) Deductible + 20% coinsurance
Part D Pharmacy ✗ No N/A N/A

Alternative Agents

If Tepezza is denied, Humana typically covers these alternatives for moderate-to-severe active TED:

  • IV methylprednisolone (first-line per consensus guidelines)
  • Orbital radiation therapy (20Gy protocol)
  • Off-label biologics: rituximab, tocilizumab (case-by-case approval)

Prior Authorization Requirements

Medical Necessity Criteria

Humana follows consensus protocols requiring:

Disease Activity & Severity:

  • Clinical Activity Score (CAS) ≥3 out of 7 points
  • Moderate-to-severe symptoms affecting daily function
  • Active inflammation documented within 90 days

Specialist Requirements:

  • Diagnosis and management by board-certified ophthalmologist
  • Endocrinology co-management for thyroid status
  • Documentation of euthyroid state or stable treatment

Prior Therapy Documentation:

  • Failed or contraindicated IV methylprednisolone course
  • Smoking cessation counseling (if applicable)
  • Baseline hearing assessment (FDA safety requirement added 2023)

Required Documentation Checklist

✓ Clinical photographs showing proptosis and lid retraction
✓ CAS scoring with individual component ratings
✓ Proptosis measurements in millimeters
✓ Steroid trial records with doses, duration, and outcomes
✓ Thyroid function tests within 30 days
✓ ICD-10 codes: H05.20 (unspecified exophthalmos) or H05.21-H05.23 (displacement of globe)

Specialty Pharmacy Coordination

Enrollment Process

Humana partners with CenterWell Specialty Pharmacy for complex biologics like Tepezza. Your provider must:

  1. Complete specialty enrollment form with patient demographics and clinical details
  2. Submit HIPAA authorization for coordination with manufacturer support programs
  3. Coordinate site of care with approved infusion centers or clinics

Distribution & Administration

  • NDC: 75987-130-15 (500mg vial)
  • Dosing: First infusion 10mg/kg, then 20mg/kg every 3 weeks × 7 doses
  • Chair time: 60-90 minutes per infusion
  • Weight-based dosing affects total vials needed (typical course: 14-20 vials)
Tip: Confirm your infusion center has an active account with Humana's approved specialty distributors to avoid delays.

Cost-Share Basics

Medicare Part B Structure

For Tepezza under Humana Medicare Advantage:

  • Annual Part B deductible: $240 (2025)
  • Your share: 20% coinsurance after deductible
  • Plan's share: 80% after deductible

Cost Example (Educational Only)

For a 180-lb patient (typical 16-vial course at ~$280,000 drug cost):

  • Medicare pays ~$224,000
  • Your maximum: ~$56,000 before supplemental coverage

Financial assistance options:

  • Horizon By Your Side copay support program
  • State pharmaceutical assistance programs
  • Medicare Supplement Insurance (Medigap) for additional coverage

Submission Process & Forms

Provider Submission Methods

Primary channels for PA requests:

  1. Humana Provider Portal (preferred for tracking)
  2. Prior Authorization Fax: 1-877-486-2621
  3. Phone: Provider services number on member ID card

Key Form Fields

When completing PA requests, emphasize:

  • Medical necessity justification with guideline references
  • Failed alternative therapies with specific doses and durations
  • Functional impairment affecting work, driving, or daily activities
  • Specialist credentials and TED experience

Expected Timeline

Request Type Standard Review Expedited Review
Initial PA 30 calendar days 72 hours (Part B)
Part D Appeals 7 calendar days 72 hours
Part B Appeals 30 calendar days 72 hours

Common Approval Patterns

Successful Submissions Include

Strong clinical narrative connecting TED symptoms to functional limitations:

  • "Patient unable to drive due to diplopia and proptosis affecting peripheral vision"
  • "Work performance impacted by eye pain and photophobia"

Quantitative measurements:

  • Proptosis >2mm difference between eyes
  • CAS scores with photo documentation
  • Visual field defects or diplopia measurements

Guideline alignment:

  • Reference to EUGOGO consensus protocols
  • FDA labeling for TED regardless of activity or duration
  • Ophthalmology society treatment recommendations

Common Denial Reasons & Fixes

Denial Reason How to Overturn
"Not active TED" Submit recent CAS scoring >3 with photos
"Steroid not tried" Document contraindications or failure with doses/dates
"Non-specialist prescriber" Transfer care to ophthalmologist
"Insufficient documentation" Add proptosis measurements, visual fields

Appeals Playbook for Washington

Internal Appeals Process

Level 1: Standard Reconsideration

  • Timeline: 60 days from denial notice
  • Submit via: Humana member portal or mail to address on EOB
  • Required: Written request with new clinical evidence
  • Decision: Within 30 days (7 days for Part D)

Level 2: Independent Review

  • Automatic if Level 1 denied
  • External reviewer: Independent medical experts
  • Timeline: Additional 30 days

Washington State External Review

After internal appeals exhausted:

  1. Request external review within 180 days of final internal denial
  2. Contact: Washington Office of the Insurance Commissioner at 1-800-562-6900
  3. Submit: Appeal request with all denial letters and clinical records
  4. Process: OIC assigns Certified Independent Review Organization (IRO)
  5. Timeline: Standard 30 days, expedited 72 hours for urgent cases
  6. Outcome: IRO decision is binding on Humana
Washington Advantage: The state's strong consumer protection laws and expert IRO network frequently overturn denials for medically necessary specialty treatments.

Expedited Appeals

Request expedited review if:

  • Waiting could seriously jeopardize your health
  • TED progression threatens vision
  • Steroid contraindications create urgent need

Required documentation:

  • Physician statement of urgency
  • Clinical evidence of rapid progression
  • Risk assessment without immediate treatment

When to Escalate

State Regulator Involvement

Contact Washington Office of the Insurance Commissioner if:

  • Humana delays exceed regulatory timelines
  • Internal appeals process appears flawed
  • You suspect unfair claim practices

How to file a complaint:

  • Online: insurance.wa.gov
  • Phone: 1-800-562-6900
  • Include: Policy number, denial letters, appeal timeline

Counterforce Health Support

When facing complex denials, specialized appeal assistance can help. Counterforce Health analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific PA criteria. Their platform identifies whether denials stem from step therapy requirements, non-formulary status, or "not medically necessary" determinations—then drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines.

For Tepezza appeals, this includes weaving together the clinical evidence Humana expects: diagnosis codes, prior steroid trials and outcomes, contraindications, weight-based dosing calculations, and treatment goals. The system produces letters that meet Humana's procedural requirements while tracking Washington's appeal deadlines.

FAQ

Q: How long does Humana prior authorization take in Washington? A: Standard PA decisions within 30 days for Part B medical benefits. Expedited reviews for urgent cases decided within 72 hours.

Q: What if Tepezza is denied as "not medically necessary"? A: Request peer-to-peer review with Humana's medical director. Emphasize CAS scoring ≥3, failed steroid therapy, and functional impairment documentation.

Q: Can I get Tepezza if I haven't tried steroids? A: Only if steroids are contraindicated (diabetes, osteoporosis, psychiatric conditions). Document specific contraindications with supporting medical records.

Q: Does Humana require step therapy for Tepezza? A: Yes, IV methylprednisolone is typically required first-line unless contraindicated. Some plans may accept oral prednisolone trials.

Q: What's the fastest way to appeal a Humana denial in Washington? A: File internal appeal immediately, request expedited review if urgent, then pursue Washington state external review if internal appeals fail.

Q: Can I use manufacturer copay cards with Humana Medicare Advantage? A: Federal law prohibits copay assistance for Medicare beneficiaries. Explore Horizon By Your Side patient assistance programs instead.

Q: How do I verify my infusion center is in-network? A: Use Humana's provider directory online or call member services. Confirm both facility and administering physician are contracted.

Q: What if my ophthalmologist won't prescribe Tepezza? A: Seek second opinion from TED specialists at major medical centers. University of Washington and Swedish Medical Center have experienced oculoplastic surgeons.

From our advocates: We've seen Washington patients successfully overturn Tepezza denials by focusing on functional impact documentation. One composite case involved a teacher whose diplopia and proptosis prevented classroom supervision—the IRO approved coverage after internal appeals failed, emphasizing how TED affected occupational safety. The key was quantifying daily life limitations, not just clinical measurements.

Disclaimer: This information is educational and not medical advice. Coverage decisions depend on your specific plan and clinical situation. Always consult your healthcare provider and verify current Humana policies through official channels.

For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900 or visit insurance.wa.gov.

Sources & Further Reading

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