By Counterforce Health Team in Tepezza (teprotumumab) —

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

Quick Answer: Getting Tepezza Covered by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab) in Ohio, with coverage limited to 8 lifetime infusions for moderate-to-severe thyroid eye disease. You'll need a Clinical Activity Score (CAS) ≥3, euthyroid thyroid labs, and documented steroid failure or contraindication. Submit through the UHC Provider Portal with complete documentation—approval typically takes 15 business days. If denied, you have 180 days to file an internal appeal, followed by Ohio's external review process through the Department of Insurance.

First step today: Call UnitedHealthcare at 1-877-842-3210 to verify your plan covers Tepezza under the medical benefit and confirm your specialist is in-network.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Ohio
  7. If You're Asked for More Information
  8. If You're Denied: Appeals Process
  9. Ohio External Review Process
  10. Renewal and Re-authorization
  11. Quick Reference Checklist

What This Guide Covers

This guide helps Ohio patients with thyroid eye disease (TED) navigate UnitedHealthcare's prior authorization process for Tepezza (teprotumumab-trbw). Whether you have a commercial employer plan, Medicare Advantage, or Medicaid managed care through UnitedHealthcare, the core requirements are similar—though specific forms and timelines may vary.

Tepezza is a breakthrough treatment for TED, but at roughly $350,000-$500,000 for the full 8-infusion course, insurers require extensive documentation before approval. The good news? With proper preparation and persistence, many patients do get coverage.

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Call UnitedHealthcare member services at 1-877-842-3210 with your member ID card ready. Ask specifically:

  • "Is Tepezza (J3241) covered under my medical benefit?"
  • "What's my prior authorization status for specialty infusions?"
  • "Is my prescribing specialist in-network?"

Coverage at a Glance

Plan Type PA Required Key Notes
Commercial/Employer Yes Submit via UHC Provider Portal
Medicare Advantage Yes May have additional step therapy requirements
Medicaid Managed Care Yes Ohio-specific criteria apply

Step 2: Verify Medical vs. Pharmacy Benefit

Tepezza is billed using HCPCS code J3241 (10 mg per unit) and is always covered under the medical benefit, not pharmacy. This means:

  • It's administered at outpatient infusion centers
  • OptumRx (UnitedHealthcare's pharmacy benefit manager) coordinates drug shipment but doesn't handle coverage decisions
  • Your medical deductible and coinsurance apply, not pharmacy copays

Gather What You Need

Required Clinical Documentation

Before submitting your prior authorization, ensure your specialist has compiled:

Essential Lab Work:

  • TSH, free T3, and free T4 levels (must be ≤30 days old)
  • Results showing euthyroid status or mild hypo/hyperthyroidism with active treatment plan

Clinical Assessment:

  • Clinical Activity Score (CAS) ≥3 out of 7 points, with detailed breakdown
  • Proptosis measurements showing ≥3mm increase from baseline (via exophthalmometry)
  • Serial photographs documenting TED progression
  • Complete ophthalmologic examination with visual field testing

Prior Treatment History:

  • Documentation of corticosteroid trial (IV methylprednisolone or high-dose oral steroids)
  • Specific doses, duration, and reason for failure or contraindication
  • Chart notes explaining why steroids weren't appropriate (e.g., diabetes, active infection)
Tip: If you have diabetes or other conditions that make steroids risky, your doctor should document this as a contraindication rather than requiring you to try and fail steroids first.

Prescriber Requirements

UnitedHealthcare requires Tepezza to be prescribed by either:

  • Board-certified ophthalmologist
  • Board-certified endocrinologist

General practitioners or other specialists typically won't meet the criteria, even with strong clinical documentation.

Submit the Prior Authorization Request

Online Submission (Fastest Method)

Your doctor should submit through the UHC Provider Portal at UHCprovider.com:

  1. Log in to Provider Portal
  2. Navigate to Prior Authorization tool
  3. Select "Medical Drug" category
  4. Enter HCPCS code J3241
  5. Upload all required documentation
  6. Submit request

Alternative Submission Methods

  • Fax: 1-844-403-1027 (for certain plan types)
  • Phone: 888-397-8129 (for urgent cases or questions)

What to Include in Your Submission

Create a complete "request packet" with:

  • Completed UnitedHealthcare prior authorization form
  • Letter of medical necessity from prescribing specialist
  • All clinical documentation listed above
  • Treatment plan outlining 8-infusion schedule
  • Copy of patient's insurance card and demographics

Follow-Up and Tracking

Monitoring Your Request

Track your prior authorization status through:

  • UHC Provider Portal: Real-time status updates
  • TrackIt System: Reference number provided at submission
  • Phone: 888-397-8129 (have reference number ready)

Sample Follow-Up Script

"Hi, I'm calling to check the status of prior authorization request [reference number] for Tepezza (teprotumumab) for patient [name]. Can you tell me if any additional information is needed and when we can expect a decision?"

Document every call with date, time, representative name, and any reference numbers provided.

Typical Timelines in Ohio

Standard Processing Times

Request Type Timeline Notes
Standard PA 15 business days Most common processing time
Expedited PA 72 hours For vision-threatening cases
Peer-to-peer review 24-48 hours Available if initial denial

Ohio-Specific Requirements

Ohio law requires insurers to process prior authorizations within reasonable timeframes, and starting January 1, 2026, new CMS rules will standardize timelines:

  • Standard requests: 7 calendar days (up to 14 with extension)
  • Expedited requests: 48-72 hours

If You're Asked for More Information

Common Additional Requests

Information Requested How to Respond
More detailed CAS scoring Submit signed 7-point CAS form with clinical photos
Steroid trial documentation Provide chart notes with specific doses, dates, and outcomes
Updated thyroid labs Obtain labs ≤30 days old showing euthyroid status
Specialist credentials Verify board certification and provide CV if requested

Responding Quickly

When UnitedHealthcare requests additional information, you typically have 10 business days to respond. Submit new documentation the same way as your original request, referencing your original prior authorization number.

If You're Denied: Appeals Process

Level 1: Internal Appeal

If your initial request is denied, you have 180 days from the denial notice to file an internal appeal.

How to Appeal:

  1. Review the denial letter carefully for specific reasons
  2. Address each denial point with additional evidence
  3. Submit appeal through Provider Portal or mail to address on denial letter
  4. Request peer-to-peer review with medical director

Common Denial Reasons and Solutions

Denial Reason Solution
"CAS score insufficient" Resubmit with detailed CAS breakdown and clinical photos
"No steroid trial documented" Provide chart notes or contraindication letter
"Patient not euthyroid" Submit recent labs and optimization plan
"Prescriber not qualified" Ensure ophthalmologist or endocrinologist is prescribing

Peer-to-Peer Review

Request a peer-to-peer review where your specialist can discuss the case directly with UnitedHealthcare's medical director. This often resolves denials when clinical complexity isn't clear from documentation alone.

Ohio External Review Process

If UnitedHealthcare upholds their denial after internal appeals, Ohio residents have additional rights under state law.

Filing an External Review

You have 180 days from UnitedHealthcare's final internal denial to request an external review through the Ohio Department of Insurance.

Timeline for External Review:

  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases

How to File:

  1. Submit request to UnitedHealthcare (they forward to Ohio DOI)
  2. Use Ohio's External Review System with OH|ID login
  3. Include all medical records and new evidence
  4. Independent Review Organization (IRO) reviews case

Contact Information:

  • Ohio DOI External Review: [email protected]
  • Phone: 614-644-0188
  • Consumer Hotline: 800-686-1526
Note: External review decisions are binding on UnitedHealthcare. If the IRO overturns the denial, your insurer must immediately provide coverage.

Renewal and Re-authorization

When Coverage Expires

Tepezza coverage is typically limited to 8 lifetime infusions, so most patients won't need renewal. However, if your treatment is interrupted or you need documentation for a different indication, be prepared to:

  • Submit updated clinical assessments
  • Provide current thyroid function tests
  • Document any changes in condition or treatment response

Calendar Reminders

Set reminders for:

  • 30 days before last approved infusion (to address any billing issues)
  • Annual insurance plan changes (to verify continued coverage)

Quick Reference Checklist

Before Starting:

  • Verify Tepezza coverage under medical benefit
  • Confirm specialist is in-network
  • Obtain current thyroid labs (≤30 days)

For Prior Authorization:

  • CAS score ≥3 with detailed breakdown
  • Proptosis measurements and photos
  • Steroid trial documentation or contraindication letter
  • Letter of medical necessity
  • 8-infusion treatment plan

If Denied:

  • Review denial letter for specific reasons
  • File internal appeal within 180 days
  • Request peer-to-peer review
  • Consider Ohio external review if needed

From Our Advocates: "We've seen many Tepezza approvals come through on appeal, especially when patients provide comprehensive documentation upfront. The key is often in the details—a well-documented CAS score with photos, clear steroid contraindication notes, and a specialist's detailed treatment rationale can make the difference between approval and denial."

For patients and healthcare providers dealing with complex prior authorization denials, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform helps identify denial reasons and draft point-by-point rebuttals using the right clinical evidence and payer-specific requirements, potentially saving weeks of back-and-forth with insurers.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Ohio? Standard processing is 15 business days, with expedited review available in 72 hours for vision-threatening cases.

What if Tepezza isn't on my formulary? Tepezza is covered under the medical benefit (not pharmacy), so formulary status doesn't apply. Prior authorization is still required.

Can I request an expedited appeal? Yes, if delays could seriously jeopardize your vision or health. Document the urgency in your appeal request.

Does step therapy apply if I failed steroids in another state? Medical records from any state showing steroid failure or contraindication should meet UnitedHealthcare's step therapy requirements.

What are my out-of-pocket costs? Costs vary by plan, but with deductibles and coinsurance, patients may face $10,000+ out-of-pocket. Check Tepezza's copay assistance program at tepezzasupport.com (1-844-695-2320).

How do I escalate if nothing works? File a complaint with the Ohio Department of Insurance at 800-686-1526 or insurance.ohio.gov. For complex cases, consider working with Counterforce Health for professional appeal assistance.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with health insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services at 800-686-1526.

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