By Counterforce Health Team in Tepezza (teprotumumab) —

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

Answer Box: Getting Tepezza Covered by UnitedHealthcare in New York

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab) with specific criteria: moderate-to-severe thyroid eye disease (CAS ≥3), euthyroid status, and documented steroid failure or contraindication. Submit through the UHC Provider Portal with complete documentation including Clinical Activity Score, thyroid labs, and treatment history. If denied, New York residents have strong appeal rights through the state's external review process managed by the Department of Financial Services. First step: Gather your CAS documentation and recent thyroid labs, then work with your ophthalmologist or endocrinologist to submit the prior authorization electronically.

Table of Contents

  1. UnitedHealthcare's Tepezza Coverage Policy
  2. Medical Necessity Requirements
  3. Step Therapy and Exception Pathways
  4. Required Documentation and Diagnostics
  5. Prior Authorization Submission Process
  6. Common Denial Reasons and Solutions
  7. Appeals Process in New York
  8. Costs and Patient Assistance
  9. When to Escalate
  10. FAQ

UnitedHealthcare's Tepezza Coverage Policy

UnitedHealthcare covers Tepezza (teprotumumab-trbw) under the medical benefit using HCPCS code J3241 (1 unit = 10 mg) for all plan types in New York: commercial employer plans, individual marketplace plans, Medicare Advantage, and Medicaid managed care. The drug requires prior authorization across all plan types, with coverage limited to 8 lifetime infusions for FDA-approved thyroid eye disease treatment.

Plan-Specific Considerations:

  • Commercial/Employer Plans: Standard 15-day PA review; OptumRx specialty pharmacy fulfillment
  • Medicare Advantage: Similar criteria with potential for expedited review (72 hours for urgent cases)
  • Medicaid Managed Care: May have additional state-specific requirements; verify with plan

The policy applies to outpatient infusion centers only—Tepezza cannot be administered at home or through retail specialty pharmacies due to monitoring requirements for this weight-based, complex infusion therapy.

Medical Necessity Requirements

FDA-Approved Indication

Tepezza is FDA-approved for thyroid eye disease (TED) regardless of activity or duration. However, UnitedHealthcare requires moderate-to-severe active disease with specific clinical criteria met.

Coverage Criteria Table

Requirement Specification Documentation Needed
Diagnosis Moderate-to-severe TED with CAS ≥3/7 OR stable disease with ≥3mm proptosis increase Ophthalmologist/endocrinologist diagnosis with CAS breakdown
Thyroid Status Euthyroid (TSH, free T3/T4 within 50% of normal) Labs within 30 days of PA submission
Prescriber Board-certified ophthalmologist or endocrinologist Provider credentials verification
Prior Treatment Failed corticosteroids OR documented contraindication Chart notes with steroid trial details
Clinical Tip: The Clinical Activity Score (CAS) is crucial. Document each of the 7 components: spontaneous orbital pain, pain on upward/side/downward gaze, eyelid redness, conjunctival redness, and eyelid/conjunctival swelling. A score ≥3 indicates active disease warranting intervention.

Step Therapy and Exception Pathways

UnitedHealthcare typically requires patients to try and fail corticosteroids before approving Tepezza. However, medical exceptions are available when steroids are contraindicated.

Required First-Line Treatments

  • IV methylprednisolone or high-dose oral corticosteroids
  • Duration: Adequate trial typically means 2-4 weeks at therapeutic doses
  • Documentation: Must include specific medications, doses, duration, and reason for discontinuation

Medical Exception Criteria

Exceptions to step therapy are granted for:

  • Diabetes mellitus (relative contraindication due to hyperglycemia risk)
  • Active infections or immunocompromised status
  • Severe psychiatric conditions worsened by steroids
  • Previous steroid intolerance with documented adverse effects
Note: Even with Tepezza approval, monitor for hyperglycemia—the FDA added warnings about hearing impairment and inflammatory bowel disease exacerbation in 2023.

Required Documentation and Diagnostics

Essential Clinical Documentation

Comprehensive Eye Exam Findings:

  • Hertel exophthalmometry measurements (proptosis in mm)
  • Visual acuity and color vision testing
  • Extraocular muscle function and diplopia assessment
  • Eyelid position and retraction measurements
  • Optic nerve evaluation

Laboratory Requirements:

  • TSH, free T4, free T3 (within 30 days)
  • Thyroid-stimulating immunoglobulin (TSI) or TRAb if available
  • Complete metabolic panel (baseline for monitoring)

Clinical Photography:

  • Baseline photographs showing orbital appearance
  • Serial images documenting progression if available
  • Standardized positioning for comparison

Clinical Activity Score Documentation

Use the standardized 7-point CAS assessment:

  1. Spontaneous orbital pain (behind the globe)
  2. Pain on attempted upward gaze
  3. Pain on attempted sideways gaze
  4. Pain on attempted downward gaze
  5. Redness of eyelids
  6. Redness of conjunctiva
  7. Swelling of eyelids, caruncle, plica, or conjunctival edema

Document each component as present (1 point) or absent (0 points). Include the total score and date of assessment in your PA submission.

Prior Authorization Submission Process

Step-by-Step PA Workflow

  1. Gather Documentation (Patient/Clinic)
    • Complete medical records, CAS scores, clinical photos
    • Recent thyroid function tests
    • Documentation of prior steroid treatment or contraindications
  2. Submit Electronic PA (Provider)
    • Use UHC Provider Portal > Prior Authorization tool
    • Include all required documentation as attachments
    • Verify correct HCPCS code J3241 and dosing calculations
  3. Track Status (Provider/Patient)
    • Monitor via UHC Provider Portal TrackIt system
    • Standard processing: 15 business days
    • Expedited review available for urgent cases (72 hours)
  4. Coordinate Infusion (Post-Approval)
    • OptumRx ships directly to network outpatient infusion center
    • Schedule treatment series (8 infusions over 21 weeks)
    • Verify insurance authorization at each visit

Submission Requirements

  • Forms: Complete PA request via electronic portal (fastest processing)
  • Fax Option: 1-844-403-1027 (verify current number)
  • Required Attachments: Medical records, lab results, clinical photos, letter of medical necessity

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient CAS documentation Resubmit with detailed 7-point CAS breakdown Complete CAS form with date and provider signature
No prior steroid trial Document previous corticosteroid use or contraindication Chart notes showing steroid trial failure or medical contraindication
Inadequate clinical records Submit comprehensive ophthalmologic evaluation Complete eye exam findings, visual fields, imaging if available
Billing/coding errors Verify correct J3241 units and modifiers Corrected billing with proper HCPCS coding
Not euthyroid Optimize thyroid function before resubmission Current labs showing TSH/T3/T4 within normal range
From Our Advocates: We've seen UnitedHealthcare approvals increase significantly when providers include clinical photographs and a detailed treatment timeline showing TED progression. The visual evidence helps reviewers understand disease severity beyond just CAS scores.

Appeals Process in New York

New York residents have robust appeal rights through both UnitedHealthcare's internal process and the state's external review system.

Internal Appeals with UnitedHealthcare

Level 1 Appeal:

  • Timeline: File within 180 days of denial
  • Process: Submit via member portal, mail, or fax
  • Decision Time: 15 business days (72 hours for urgent)
  • Required: Address each specific denial reason with supporting evidence

Level 2 Appeal (if available):

  • Timeline: 60 days from Level 1 denial
  • Process: Same submission methods
  • Peer-to-Peer: Request physician-to-physician review

New York External Review Process

After exhausting internal appeals, New York law provides independent external review through the Department of Financial Services (DFS).

Eligibility Requirements:

  • Must complete UnitedHealthcare's internal appeal process first
  • Denial must involve medical necessity, experimental treatment, or formulary issues
  • File within 4 months of final internal denial

Filing Process:

  1. Submit Application: Use NY External Appeal Application form
  2. Fee: $25 (waived for financial hardship, refunded if you win)
  3. Documentation: Include all medical records, denial letters, supporting literature
  4. Timeline: Standard review 30-45 days; expedited 72 hours (24 hours for urgent drug denials)

Success Rates: New York's external review process overturns approximately 50-60% of insurance denials, with independent medical experts making binding decisions.

Getting Help with Appeals

Community Health Advocates (CHA) provides free assistance to New York residents:

  • Phone: 888-614-5400
  • Services: Help filing appeals, searching precedent database, understanding rights
  • Database: Searchable external appeals database for similar cases

Key Case: DFS case 202211-155790 shows a successful external review overturning UnitedHealthcare's denial for Tepezza retreatment, demonstrating the process works for this specific medication.

Costs and Patient Assistance

Expected Costs

  • Drug Cost: ~$17,511 per 500mg vial (March 2025 WAC pricing)
  • Full Course: $350,000-$500,000+ depending on patient weight
  • Patient Responsibility:
    • Commercial plans: 10-30% coinsurance after deductible
    • Medicare Part B: 20% coinsurance
    • Medicaid: Minimal copays

Patient Assistance Programs

Amgen By Your Side Program:

  • Copay assistance for eligible commercially insured patients
  • May reduce out-of-pocket costs to $0 for qualifying patients
  • Income and insurance requirements apply
  • Apply at amgenbyyourside.com

Foundation Grants:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

Counterforce Health helps patients navigate these complex coverage decisions by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific criteria needed for approval, then drafts point-by-point rebuttals using the right clinical evidence and payer-specific workflows.

When to Escalate

Contact New York Regulators

If you believe UnitedHealthcare is improperly denying coverage or not following appeal timelines:

New York Department of Financial Services

  • Consumer Hotline: 1-800-342-3736
  • Online Complaints: dfs.ny.gov/complaints
  • Issues to Report: Delayed processing, improper denials, failure to follow state law

Consider legal advice if:

  • Multiple appeal levels have failed
  • You suspect bad faith denial practices
  • Emergency treatment is being delayed
  • ERISA plan issues (self-insured employer plans)

Checklist: What to Gather Before You Start

Before beginning your Tepezza prior authorization:

Patient Information:

  • UnitedHealthcare member ID card
  • Current thyroid function tests (within 30 days)
  • Complete medical history including prior TED treatments
  • Clinical photographs showing orbital changes

Provider Documentation:

  • Comprehensive ophthalmologic examination
  • Clinical Activity Score (CAS) assessment
  • Documentation of steroid trial or contraindications
  • Letter of medical necessity
  • Treatment plan for 8-infusion course

Insurance Verification:

  • Confirm prior authorization requirement
  • Verify network infusion center options
  • Check annual deductible and coinsurance amounts

FAQ

How long does UnitedHealthcare prior authorization take for Tepezza in New York? Standard review is 15 business days. Expedited review (72 hours) is available for urgent cases where delay could worsen vision or cause irreversible damage.

What if Tepezza is non-formulary on my UnitedHealthcare plan? Even non-formulary drugs can be covered with prior authorization when medically necessary. The same clinical criteria apply, but you may face higher coinsurance.

Can I request an expedited appeal in New York? Yes. Both UnitedHealthcare internal appeals and New York external reviews offer expedited processing (72 hours) when delay poses health risks.

Does step therapy apply if I tried steroids outside New York? Yes, prior steroid trials from any location count toward step therapy requirements. Provide complete documentation from out-of-state providers.

What happens if my weight changes during treatment? Tepezza dosing is weight-based (10 mg/kg for first infusion, 20 mg/kg for subsequent). Significant weight changes may require PA modification for proper dosing.

Can my primary care doctor prescribe Tepezza? No. UnitedHealthcare requires prescribers to be board-certified ophthalmologists or endocrinologists with TED experience.

What if I'm pregnant or planning pregnancy? Tepezza is not recommended during pregnancy. Discuss family planning with your physician, as TED often improves during pregnancy naturally.

How do I find a network infusion center in New York? Use UnitedHealthcare's provider directory online or call member services. OptumRx coordinates with network facilities post-approval.

This guide provides educational information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan and clinical circumstances. For personalized guidance, consult your healthcare provider and review your plan documents.

Need help with a Tepezza denial? Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial reasons and crafting evidence-based responses that meet your plan's exact requirements.

Sources & Further Reading

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