By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (Teprotumumab) Covered by UnitedHealthcare in Georgia: Prior Authorization Guide and Appeal Process

Answer Box: Getting Tepezza Covered by UnitedHealthcare in Georgia

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab) with specific criteria: moderate-to-severe thyroid eye disease diagnosed by an ophthalmologist/endocrinologist, euthyroid status, documented corticosteroid trial or contraindication, and Clinical Activity Score ≥3. Fastest path: Have your specialist submit a complete PA request through the UnitedHealthcare Provider Portal with clinical documentation, recent thyroid labs, and prior treatment records. If denied, you have 180 days for internal appeal and 60 days for Georgia external review through the Georgia Department of Insurance.

Table of Contents

Policy Overview: UnitedHealthcare Plans in Georgia

UnitedHealthcare operates multiple plan types in Georgia, including employer-sponsored commercial plans, Medicare Advantage, and select individual marketplace plans. All UnitedHealthcare plans require prior authorization for Tepezza, but specific criteria may vary slightly between commercial and Medicare plans.

The current UnitedHealthcare Medical Benefit Drug Policy for Tepezza (effective March 2025) applies across all plan types and establishes the foundation for coverage decisions.

Coverage at a Glance

Requirement Details Documentation Needed
Prior Authorization Required for all plans Complete PA form via provider portal
Formulary Status Medical benefit (J3241) HCPCS billing code
Prescriber Ophthalmologist or endocrinologist Specialty verification
Diagnosis Moderate-to-severe TED ICD-10: E05.00, H06.2*
Maximum Doses 8 infusions per lifetime Treatment plan documentation
Site of Care Outpatient infusion center Network provider required

Medical Necessity Requirements for Tepezza

UnitedHealthcare's medical necessity criteria for Tepezza are specific and must be documented thoroughly. The insurer follows FDA labeling closely but adds additional requirements for coverage approval.

Core Eligibility Criteria

Diagnosis Requirements:

  • Documented moderate-to-severe thyroid eye disease (TED)
  • Clinical Activity Score (CAS) ≥3 out of 7 points
  • Proptosis measurements showing ≥3mm above normal or progression
  • Age 18 years or older

Laboratory Requirements:

  • Euthyroid status or thyroid levels within 50% of normal limits
  • Recent thyroid function tests (TSH, free T3, free T4) within 30 days
  • Documentation of Graves' disease if applicable

Treatment History:

  • Prior corticosteroid trial with inadequate response, OR
  • Documented contraindication to corticosteroids, OR
  • Intolerance to systemic steroids with clinical evidence
Clinician Corner: Medical Necessity Letter Checklist

Include these elements in your PA request:Patient demographics and insurance informationComplete TED diagnosis with ICD-10 codes (E05.00, H06.2*)Clinical Activity Score breakdown (list each positive sign)Proptosis measurements in millimetersPrior treatment history and outcomesCurrent thyroid function labs with datesProposed dosing schedule (10 mg/kg initial, then 20 mg/kg q3 weeks)Clinical rationale citing FDA labeling or peer-reviewed guidelines

Step Therapy and Exception Pathways

Unlike many specialty medications, Tepezza is not subject to formal step therapy requirements under current UnitedHealthcare policies. However, the insurer requires documentation of prior corticosteroid use or valid medical reasons for avoiding steroids.

Exception Pathways

Medical Contraindications to Steroids:

  • Uncontrolled diabetes mellitus
  • Active peptic ulcer disease
  • Severe osteoporosis with fracture history
  • Active systemic infection
  • Psychiatric contraindications (severe mood disorders)

Documented Steroid Intolerance:

  • Previous severe adverse reactions
  • Inadequate response to appropriate steroid course
  • Patient-specific factors preventing steroid use

When documenting exceptions, provide specific clinical details and timeframes. Generic statements like "patient cannot tolerate steroids" are insufficient for approval.

Required Clinical Documentation

Comprehensive clinical documentation is critical for Tepezza approval. UnitedHealthcare reviews each case for medical necessity, and incomplete documentation is a leading cause of denials.

Essential Documentation Elements

Ophthalmology Assessment:

  • Clinical Activity Score (CAS) with individual component scores
  • Hertel exophthalmometry measurements (proptosis in mm)
  • Eyelid retraction measurements
  • Extraocular muscle function and diplopia assessment
  • Visual acuity and visual field testing
  • Baseline photographs if available

Laboratory Data:

  • Thyroid function tests (TSH, free T3, free T4) within 30 days
  • Thyroid-stimulating immunoglobulin (TSI) or TRAb if available
  • Complete metabolic panel including glucose

Treatment History:

  • Previous corticosteroid regimens with doses, duration, and outcomes
  • Any other TED treatments attempted (selenium, radiation therapy)
  • Contraindications to alternative therapies
  • Patient-reported symptom severity and functional impact
Tip: Include quantitative measurements whenever possible. Instead of "mild proptosis," document "proptosis 22mm OD, 21mm OS (normal <20mm)."

Billing and Specialty Pharmacy Requirements

Tepezza is billed under the medical benefit using HCPCS code J3241, where each unit represents 10mg of teprotumumab. The medication comes in 500mg vials, so a typical dose requires billing 50 units per vial used.

Billing Essentials

HCPCS Coding:

  • J3241: Injection, teprotumumab-trbw, 10 mg
  • Bill total dose in 10mg increments
  • Use JW modifier for documented drug wastage
  • Include appropriate infusion administration codes (96413, 96415)

Specialty Pharmacy Requirements:

  • Tepezza must be obtained through UnitedHealthcare's specialty pharmacy network
  • OptumRx Specialty Pharmacy typically handles fulfillment
  • Coordinate with infusion center for delivery and administration scheduling
  • Prior authorization must be approved before drug shipment

Dosing and Administration

The FDA-approved regimen consists of 8 intravenous infusions:

  • Initial dose: 10 mg/kg administered over 60-90 minutes
  • Subsequent doses: 20 mg/kg every 3 weeks for 7 additional infusions
  • Total treatment duration: Approximately 21 weeks

Appeals Process in Georgia

If UnitedHealthcare denies your Tepezza request, Georgia law provides a structured appeals process with specific timelines and requirements.

Internal Appeals Process

Timeline: 180 days from denial notice to file internal appeal Expedited Review: Available if delay could jeopardize health (72-hour decision) Submission Options:

  • UnitedHealthcare Provider Portal (preferred)
  • Mail to address specified in denial letter
  • Fax to number provided in denial notice

Georgia External Review Process

If internal appeals are unsuccessful, Georgia residents can request external review through the Georgia Office of Commissioner of Insurance.

Key Requirements:

  • Must file within 60 days of final internal denial
  • External review is free for consumers
  • Independent medical reviewers make binding decisions
  • Standard review completed within 30 business days
  • Expedited review available for urgent cases (72 hours)
Note: Georgia's external review process is binding on insurers. If reviewers determine Tepezza is medically necessary, UnitedHealthcare must provide coverage.

Appeals Documentation Checklist

  • Complete denial letter from UnitedHealthcare
  • All medical records supporting medical necessity
  • Specialist letters explaining why Tepezza is required
  • Documentation of failed prior treatments
  • Recent laboratory results
  • Patient impact statement (functional limitations)

Common Denial Reasons and Solutions

Understanding common denial patterns can help you prepare stronger initial requests and more effective appeals.

Denial Reason Solution Strategy Required Documentation
Insufficient CAS documentation Provide detailed CAS breakdown Individual component scores, not just total
Missing thyroid labs Submit recent lab results TSH, free T3, free T4 within 30 days
Inadequate prior treatment history Document steroid trial or contraindications Specific regimens, doses, outcomes, or medical contraindications
Non-specialty prescriber Transfer care or obtain consultation Ophthalmology or endocrinology involvement
Incomplete proptosis measurements Provide Hertel exophthalmometry Measurements in millimeters for both eyes
Missing medical necessity justification Submit comprehensive clinical rationale Functional impact, treatment goals, prognosis

Cost Assistance and Support Programs

Even with insurance coverage, Tepezza can involve significant out-of-pocket costs. Several programs may help reduce financial burden.

Manufacturer Support Programs

Amgen By Your Side:

  • Copay assistance for eligible commercially insured patients
  • Prior authorization support services
  • Patient education and injection site locator
  • Contact: amgenbyyourside.com

Additional Resources

Patient Assistance Foundations:

  • HealthWell Foundation
  • Patient Access Network Foundation
  • National Organization for Rare Disorders (NORD)
  • The Assistance Fund

State-Specific Resources:

  • Georgia Department of Community Health (Medicaid)
  • Georgia Legal Services Program (appeals assistance)
  • Georgians for a Healthy Future (consumer advocacy)

For patients facing coverage challenges, Counterforce Health offers AI-powered tools to help analyze denial letters and generate targeted appeal letters based on your specific insurance policy and clinical situation. Their platform can help identify the strongest arguments for medical necessity and ensure your appeal addresses the insurer's specific criteria.

FAQ: Tepezza Coverage Questions

Q: How long does UnitedHealthcare prior authorization take in Georgia? A: Standard prior authorization decisions are typically made within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if my ophthalmologist isn't in the UnitedHealthcare network? A: You may need to obtain a referral to an in-network specialist or request a network adequacy exception if no in-network TED specialists are available in your area.

Q: Can I appeal if I don't meet the Clinical Activity Score requirement? A: Yes. If you have moderate-to-severe TED with significant functional impact despite a CAS <3, document other severity indicators like proptosis progression, diplopia, or vision-threatening complications.

Q: Does UnitedHealthcare cover Tepezza for cosmetic concerns? A: No. Coverage is limited to medically necessary treatment of thyroid eye disease with documented functional impairment or vision-threatening complications.

Q: What happens if I need more than 8 infusions? A: Additional infusions beyond the standard 8-dose regimen require separate prior authorization with peer-reviewed literature supporting extended treatment.

Q: How do I request an expedited appeal in Georgia? A: Mark your appeal as "URGENT" and include clinical documentation showing that delay could seriously jeopardize your health or vision. Both UnitedHealthcare and Georgia external review offer expedited processes.

Q: Can I get Tepezza covered if I'm currently hyperthyroid? A: Coverage typically requires euthyroid status or thyroid levels within 50% of normal limits. Work with your endocrinologist to optimize thyroid function before requesting authorization.

Q: What if UnitedHealthcare requires step therapy that isn't in their written policy? A: Document this discrepancy and file a complaint with Georgia Department of Insurance. Insurers must follow their published policies consistently.

From our advocates: We've seen successful appeals where patients initially received denials for "insufficient documentation" but won coverage after providing detailed CAS scores, proptosis measurements, and comprehensive treatment histories. The key is often in the specificity of clinical documentation rather than just meeting basic criteria.

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or a guarantee of coverage. Always consult with your healthcare providers about treatment decisions and verify current policy requirements with UnitedHealthcare directly.

For additional support with insurance appeals and coverage challenges, Counterforce Health provides specialized tools and resources to help patients and clinicians navigate prior authorization requirements and develop evidence-based appeal strategies.

Sources & Further Reading

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