By Counterforce Health Team in Tepezza (teprotumumab) —

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

Answer Box: Tepezza Coverage with UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab) in New Jersey for moderate-to-severe thyroid eye disease. Your ophthalmologist or endocrinologist must submit documentation showing Clinical Activity Score ≥3, euthyroid status, and failed corticosteroid treatment via the UHC Provider Portal. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) offers free external review within 180 days. Start today: Gather your thyroid labs, CAS scores, and photos showing TED progression.

Table of Contents

  1. Coverage Basics: Is Tepezza Covered?
  2. Prior Authorization Process
  3. Documentation Requirements
  4. Timeline and Status Tracking
  5. Coverage Criteria Breakdown
  6. Cost and Copay Assistance
  7. Denials and Appeals in New Jersey
  8. Specialty Pharmacy Coordination
  9. Common Problems and Solutions
  10. Frequently Asked Questions

Coverage Basics: Is Tepezza Covered?

UnitedHealthcare covers Tepezza (teprotumumab-trbw) under the medical benefit for moderate-to-severe thyroid eye disease in adults, but prior authorization is required for all plan types in New Jersey:

Plan Type PA Required Key Notes
Commercial/Employer Yes Submit via Provider Portal or fax 1-844-403-1027
Medicare Advantage Yes Follows similar criteria, may have plan-specific variations
ACA/Marketplace Yes Electronic submission preferred for faster processing

Tepezza is billed under HCPCS code J3241 (10 mg per unit) and limited to 8 lifetime infusions per FDA labeling. The drug ships from OptumRx specialty pharmacy directly to network outpatient infusion centers only after PA approval.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify coverage (Patient/Clinic): Check member ID card and call UHC at 1-877-842-3210 to confirm plan type and PA requirements.
  2. Gather documentation (Clinic): Collect CAS scores, proptosis measurements, clinical photos, recent thyroid labs (within 30 days), and steroid trial records.
  3. Submit PA electronically (Prescriber): Use UHC Provider Portal > Prior Authorization tool for fastest processing (15 business days standard).
  4. Track status (Clinic): Monitor via portal TrackIt system or call provider services for updates.
  5. Coordinate fulfillment (Clinic): Upon approval, OptumRx ships to designated infusion center; verify NDC requirements before billing.
  6. Bill correctly (Clinic): Use J3241 in 10mg units, JW modifier for wastage, plus infusion codes 96413/96415.
  7. Monitor for renewals (Ongoing): PA typically covers full 8-infusion course; no mid-treatment reauthorization needed unless plan changes.

Documentation Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
Moderate-to-severe TED Clinical Activity Score ≥3/7 OR stable disease with ≥3mm proptosis increase Ophthalmology notes, CAS worksheet UHC Policy PDF
Euthyroid status TSH, free T3/T4 within 50% of normal limits Lab results within 30 days UHC Policy PDF
Prior steroid trial Failed corticosteroids or documented contraindication Chart notes on dose, duration, outcome UHC Policy PDF
Specialist prescriber Board-certified ophthalmologist or endocrinologist Provider credentials, treatment plan UHC Policy PDF
Clinical photos Serial images showing TED progression/severity Digital photos with measurements Tepezza HCP Guide

Clinician Corner: Medical Necessity Letter Checklist

When writing your medical necessity letter, include:

  • Patient demographics and TED diagnosis with ICD-10 codes (E05.00, H05.20, H06.2*)
  • CAS component breakdown (pain, redness, swelling, chemosis, caruncle, lid retraction, restriction)
  • Functional impact (diplopia, vision loss, inability to close eyes, psychosocial effects)
  • Prior treatments with specific regimens, doses, durations, and outcomes
  • Contraindications to alternatives (diabetes, osteoporosis, psychiatric history)
  • Treatment plan following FDA dosing (10 mg/kg once, then 20 mg/kg × 7 infusions)
  • Monitoring plan for hearing, blood glucose, and IBD symptoms

Timeline and Status Tracking

Processing Timelines

  • Standard PA decision: 15 business days from complete submission
  • Expedited review: 72 hours for urgent cases (vision-threatening complications)
  • Peer-to-peer review: Available within 24 hours of initial denial
  • Status updates: Real-time via UHC Provider Portal TrackIt system
Tip: Request expedited review if TED is causing severe functional impairment or vision loss. Document urgency in your submission.

Coverage Criteria Breakdown

UnitedHealthcare's updated policy (effective March 1, 2025) requires ALL of the following:

Primary Criteria

  • Age: 18 years or older
  • Diagnosis: Moderate-to-severe TED with either:
    • Clinical Activity Score ≥3 out of 7, OR
    • Stable/chronic inactive disease with ≥3mm proptosis increase from pre-TED baseline
  • Thyroid status: Euthyroid (TSH and free T3/T4 within 50% of normal range)
  • Prior therapy: Inadequate response, intolerance, or contraindication to corticosteroids
  • Prescriber: Board-certified ophthalmologist or endocrinologist

Exclusions

  • Active hyperthyroidism (must be treated and stable first)
  • Cosmetic use without functional impairment
  • More than 8 lifetime infusions
  • Pregnancy (Category C, insufficient safety data)

Cost and Copay Assistance

Out-of-Pocket Costs

Tepezza costs approximately $17,511 per 500mg vial at wholesale acquisition cost, with full treatment courses ranging $350,000-$500,000+ depending on patient weight. After UHC coverage:

  • Commercial plans: Typically 10-30% coinsurance after deductible
  • Medicare Advantage: Usually 20% coinsurance under Part B medical benefit
  • High-deductible plans: May require meeting full deductible first

Patient Support Programs

  • Tepezza CoPay Program: Up to $25,000/year assistance for eligible commercial and Medicare patients
  • Application: Visit tepezzasupport.com or call 1-844-695-2320
  • Eligibility: Income limits apply; must have UHC coverage and PA approval

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements and turn insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed rebuttals that address payer-specific criteria and procedural requirements.

Denials and Appeals in New Jersey

Common Denial Reasons & Fixes

Denial Reason How to Fix Documentation Needed
Insufficient CAS documentation Resubmit detailed component scores and photos CAS worksheet, clinical photos, specialist notes
Missing thyroid labs Submit recent results TSH, free T3, free T4 within 30 days
No prior steroid trial Document trial or contraindication Chart notes on specific regimen, outcome, or medical reasons for avoidance
Wrong prescriber specialty Add ophthalmology/endocrinology consult Specialist evaluation and treatment recommendation
Billing/coding errors Correct HCPCS units and modifiers J3241 in 10mg increments, JW for wastage

New Jersey Appeals Process

Internal Appeals (UnitedHealthcare)

  • Timeline: File within 60 days of denial for outpatient PA
  • UHC response: 30 days standard, 72 hours expedited
  • Method: UHC Provider Portal or mail with denial letter and supporting records
  • Second level: Available for group plans before external review

External Review (IHCAP)

New Jersey's Independent Health Care Appeals Program provides free, binding external review:

  • Eligibility: After completing UHC internal appeals for medical necessity denials
  • Timeline: File within 180 days of final internal denial
  • Process: Submit directly to Maximus Federal Services (contracted IURO)
  • Decision time: 45 days standard, 48 hours expedited
  • Contact: 1-888-393-1062 or NJ DOBI IHCAP page
  • Success rate: Approximately 50% of external appeals favor consumers nationwide
From our advocates: We've seen cases where UnitedHealthcare initially denied Tepezza for "insufficient CAS documentation," but the external reviewer overturned the denial when the specialist provided detailed component scores and functional impact statements. The key was showing how even a CAS of 3 caused significant diplopia affecting the patient's ability to drive safely.

Specialty Pharmacy Coordination

OptumRx Requirements

  • Fulfillment: OptumRx ships Tepezza to network infusion centers only
  • Billing: Facility bills UHC for drug (J3241) and administration codes
  • Coordination: Confirm PA approval before scheduling; verify NDC requirements
  • Wastage: Use JW modifier for partial vial disposal per FDA single-use labeling

Site of Care

UHC restricts Tepezza to outpatient hospital or infusion center settings due to:

  • Infusion reaction monitoring requirements
  • Weight-based dosing complexity
  • Specialized preparation and administration protocols

Common Problems and Solutions

Portal Issues

  • Provider Portal down: Call UHC provider services at 1-877-842-3210
  • Missing forms: Download current PA forms from UHCprovider.com
  • Status unclear: Use TrackIt system or request peer-to-peer review

Documentation Problems

  • Old thyroid labs: Reorder within 30-day window
  • Incomplete CAS: Use standardized worksheet with photo documentation
  • Missing steroid history: Contact previous providers for treatment records

Billing Rejections

  • Wrong units: J3241 is per 10mg (50 units for 500mg vial)
  • Missing PA: Verify approval number and effective dates
  • Site restrictions: Confirm network infusion center participation

Frequently Asked Questions

How long does UnitedHealthcare PA take in New Jersey? Standard processing is 15 business days. Expedited review (72 hours) is available for urgent cases with vision-threatening complications.

What if Tepezza is non-formulary on my plan? Tepezza is typically covered under the medical benefit (J3241), not pharmacy formulary. Prior authorization is still required regardless of formulary status.

Can I request an expedited appeal? Yes, if delay would cause serious harm to your health. Document urgency and vision-threatening symptoms in your appeal.

Does step therapy apply if I failed steroids outside New Jersey? Yes, UHC accepts prior treatment failures from other states. Include complete medical records and specialist notes.

What happens if I'm denied after 8 infusions? FDA labeling limits Tepezza to 8 infusions lifetime. Additional treatment is considered investigational and typically not covered.

Can my doctor file the appeal for me? Yes, providers can file appeals on behalf of patients. Many specialists prefer this approach for complex cases.

How much will I pay out-of-pocket? Costs vary by plan. After PA approval, typical coinsurance is 10-30%. Apply for copay assistance before starting treatment.

What if UHC changes my plan mid-treatment? Contact UHC immediately to transfer PA approval. Mid-treatment plan changes should not interrupt ongoing therapy.

When dealing with complex prior authorization requirements and potential denials, Counterforce Health provides specialized support to help patients and providers build stronger appeals. Their evidence-based approach has helped many patients successfully overturn initial denials by addressing specific payer criteria and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by plan and change over time. Always verify current requirements with your insurance plan and consult healthcare professionals for medical decisions. For personalized assistance with appeals and prior authorizations, contact the New Jersey Department of Banking and Insurance at 1-800-446-7467.

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