By Counterforce Health Team in Tepezza (teprotumumab) —

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

Answer Box: Getting Tepezza Covered by UnitedHealthcare in Illinois

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab, HCPCS J3241) under the medical benefit. To get approval: 1) Submit PA via UHC Provider Portal with thyroid eye disease diagnosis, Clinical Activity Score ≥3, recent thyroid labs, and documented steroid trial/contraindication. 2) If denied, file internal appeal within 180 days. 3) Use Illinois external review through IDOI within 4 months of final denial. Illinois residents have strong appeal protections with binding external review decisions.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans UHC Provider Portal UHC PA Requirements
Diagnosis Moderate-to-severe thyroid eye disease Specialist documentation UHC Tepezza Policy
Clinical Activity Score CAS ≥3 or documented active disease Ophthalmology/endocrinology notes UHC Tepezza Policy
Step Therapy Trial/contraindication to corticosteroids Treatment history documentation UHC Tepezza Policy
Thyroid Status Euthyroid or within 50% of normal TSH, free T3, free T4 within 30 days UHC Tepezza Policy
Prescriber Board-certified ophthalmologist or endocrinologist Provider credentials UHC Tepezza Policy
Billing Code HCPCS J3241 (medical benefit) Claims processing UHC Provider Resources
Course Limit 8 infusions per lifetime Policy restrictions UHC Tepezza Policy

Step-by-Step: Fastest Path to Approval

1. Verify Plan Type and Coverage

  • Check your UnitedHealthcare ID card for plan type (Commercial, Medicare Advantage, Community Plan)
  • Confirm Tepezza is covered under medical benefit with J3241 code
  • Timeline: Same day
  • Who: Patient or clinic staff

2. Gather Required Documentation

  • Clinical Activity Score with component breakdown
  • Proptosis measurements in millimeters
  • Recent thyroid function tests (TSH, free T3, free T4 within 30 days)
  • Documentation of steroid trial or contraindication
  • Timeline: 1-2 days
  • Who: Treating specialist

3. Submit Prior Authorization

  • Use UHC Provider Portal → Prior Authorization & Notification → Medical Benefit Drug
  • Select Tepezza/J3241 and complete all clinical fields
  • Upload supporting PDFs (notes, labs, photos)
  • Timeline: Submit within 1-2 business days
  • Who: Prescriber or clinic staff

4. Track Decision

  • Standard PA decisions within 15 business days
  • Expedited/urgent cases within 72 hours
  • Check status via provider portal or call UHC
  • Timeline: 2-15 business days
  • Who: Clinic staff monitors

5. If Approved: Coordinate Specialty Pharmacy

  • Enroll with Optum Specialty Pharmacy at specialty.optumrx.com or call 1-855-427-4682
  • Confirm infusion site shipping details
  • Schedule first infusion
  • Timeline: 3-5 business days after approval
  • Who: Patient and clinic coordinate

6. If Denied: File Internal Appeal

  • Submit appeal within 180 days via UHC member portal or mail/fax per denial letter
  • Include additional clinical documentation and medical necessity letter
  • Timeline: Must file within 180 days; decision in 30 days
  • Who: Patient with provider support

7. If Appeal Denied: Request Illinois External Review

  • File with Illinois Department of Insurance within 4 months
  • Use IDOI External Review Form
  • Timeline: File within 4 months; decision in 45 days
  • Who: Patient or authorized representative

Prior Authorization Forms and Submission

Finding the Correct Forms

UnitedHealthcare processes Tepezza prior authorizations through different channels depending on your plan type:

  • Commercial Plans: Use the UHC Provider Portal medical benefit drug PA tool
  • Medicare Advantage: Submit via the same portal, selecting Medicare plan type
  • Community Plan (Medicaid): Electronic submission required starting 2025

Required Clinical Documentation

Your prior authorization must include:

Diagnosis Documentation:

  • ICD-10 codes (E05.00 for thyrotoxicosis, H06.2* for TED-related codes)
  • Clinical Activity Score with itemized components, not just total
  • Proptosis measurements (mm) for both eyes
  • Documentation of diplopia, lid retraction, chemosis, or pain

Laboratory Results:

  • TSH, free T3, free T4 within 30 days of request
  • Evidence of euthyroid or near-euthyroid status

Treatment History:

  • Detailed steroid therapy history: specific agents, doses, duration, outcomes
  • If steroids contraindicated: specific medical reasons documented
  • Any prior orbital radiation, surgery, or other TED therapies

Prescriber Information:

  • Board certification in ophthalmology or endocrinology
  • Specialty clinic affiliation and experience with TED

Submission Options

  1. Electronic (Preferred): UHC Provider Portal
  2. Fax: 1-844-403-1027 (verify with current plan materials)
  3. CoverMyMeds: Integrated with OptumRx for medical drug PAs
Tip: Electronic submissions process faster and provide real-time status tracking.

Specialty Pharmacy Enrollment

Optum Specialty Pharmacy Requirements

UnitedHealthcare typically requires Tepezza to be dispensed through Optum Specialty Pharmacy for most plans. This is mandated on UHC's specialty pharmacy requirements list.

Enrollment Process:

  1. Patient Registration: Call 1-855-427-4682 or register online at specialty.optumrx.com
  2. Benefits Verification: Optum confirms PA status and cost-sharing
  3. Shipping Coordination: Drug ships to infusion center, not patient's home
  4. Scheduling: Coordinate with infusion site for delivery timing

Transfer from Another Specialty Pharmacy

If you're switching to UnitedHealthcare mid-treatment:

  • Specialty prescriptions do NOT automatically transfer
  • Call Optum Specialty immediately after new coverage starts
  • Optum will contact your prescriber to obtain a new prescription
  • Consider filing a Transition of Care request to maintain coverage during the switch
Note: Don't assume refills will move automatically. Contact Optum Specialty as soon as your new UHC plan is effective.

Common Denial Reasons and Solutions

Denial Reason How to Fix Required Documentation
Insufficient CAS documentation Resubmit with component-by-component breakdown Detailed CAS scoring with each element
Missing thyroid labs Provide recent labs TSH, free T3, free T4 within 30 days
No documented steroid trial Add treatment history or contraindication Specific drugs, doses, outcomes, or medical contraindications
Wrong billing code Correct coding submission Use HCPCS J3241 with proper unit calculation
Non-specialty prescriber Get specialist consultation Ophthalmology or endocrinology evaluation
Disease not active enough Document disease severity Photos, measurements, functional impact

Appeals Process for Illinois Residents

Internal Appeals with UnitedHealthcare

Timeline: File within 180 days of denial date Process:

  1. Submit via UHC member portal, mail, or fax (per denial letter instructions)
  2. Include denial letter, additional clinical documentation, and medical necessity letter
  3. Decision typically within 30 days (expedited cases within 72 hours)

Illinois External Review Rights

Illinois residents have strong external review protections under the Health Carrier External Review Act.

Key Benefits:

  • Independent physician reviewer with TED expertise
  • Binding decision on UnitedHealthcare
  • No cost to consumers
  • Enhanced protections effective 2025

Filing Process:

  1. Complete UHC's internal appeal process (except for urgent/experimental cases)
  2. File IDOI External Review Form within 4 months
  3. Include all medical documentation and UHC's final denial
  4. Decision within 45 days (expedited cases much faster)

Contact for Help: Illinois Department of Insurance at 877-850-4740

When Cases Qualify as Urgent

Illinois expanded the definition of urgent cases to include:

  • Severe pain or significant potential for deterioration
  • Vision-threatening TED progression
  • Risk of permanent functional impairment

Urgent cases can pursue internal appeals and external review simultaneously.

Support Resources and Contact Information

UnitedHealthcare Contacts

  • Member Services: Number on your ID card
  • Provider Services: 1-800-842-3211
  • Prior Authorization Status: UHC Provider Portal

Illinois Consumer Assistance

  • Department of Insurance External Review: 877-850-4740
  • Attorney General Health Care Helpline: 1-877-305-5145
  • Consumer Health Insurance Office: 877-527-9431

Manufacturer Support

  • Amgen By Your Side: Support program for Tepezza patients
  • Financial assistance and copay support available
  • Contact through prescriber or patient services

FAQ

How long does UnitedHealthcare PA take for Tepezza in Illinois? Standard decisions within 15 business days; expedited/urgent cases within 72 hours when delay threatens vision.

What if Tepezza is denied as experimental/investigational? This qualifies for Illinois external review. File with IDOI using the experimental/investigational pathway, which allows expedited processing.

Can I appeal if I'm in an employer self-funded plan? Self-funded plans may follow different rules. Contact IDOI at 877-850-4740 to confirm whether Illinois external review applies to your specific plan.

Does step therapy apply if I failed steroids in another state? Yes, documented steroid failure from any provider/state should satisfy UHC's step therapy requirement. Include complete treatment records.

What's the success rate for external reviews in Illinois? While specific rates vary, independent external reviews nationwide overturn insurer denials in approximately 25-50% of cases when medical evidence supports the treatment.

Can I get more than 8 Tepezza infusions? UHC's policy limits coverage to 8 lifetime infusions. Additional courses require exceptional justification and are commonly denied as not medically necessary.

What if my infusion center isn't in UHC's network? You may request a network adequacy exception if no in-network facility can provide Tepezza infusions within reasonable distance. Document the lack of network options.

How do I expedite an appeal for vision-threatening TED? Have your ophthalmologist document the urgent nature and submit an expedited appeal request. Include clinical evidence of rapid progression or vision risk.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address each payer's specific criteria. For complex cases like Tepezza denials, we help identify the exact clinical documentation needed and draft point-by-point rebuttals aligned to UnitedHealthcare's own coverage rules.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For complex appeals, consider working with Counterforce Health or consulting with a healthcare attorney familiar with Illinois insurance law.

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