By Counterforce Health Team in Tepezza (teprotumumab) —

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

Answer Box: Getting Tepezza Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab) in Pennsylvania through OptumRx. You need: moderate-to-severe thyroid eye disease diagnosed by an ophthalmologist/endocrinologist, euthyroid status, and prior corticosteroid trial or contraindication. Submit via UHC Provider Portal or fax to 1-844-403-1027. If denied, file internal appeal within 180 days, then Pennsylvania external review within 4 months at reviewmyclaim.pa.gov. Pennsylvania's external review overturns ~50% of denials.

First step today: Verify your UnitedHealthcare plan type and gather thyroid labs, CAS scores, and steroid trial documentation.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process: Internal & Pennsylvania External Review
  6. Support Lines & Contacts
  7. Pennsylvania Consumer Protection Resources
  8. Common Denial Reasons & How to Fix Them
  9. FAQ

Verify Your Plan & Find the Right Forms

Before starting your Tepezza prior authorization, confirm your specific UnitedHealthcare plan type. This determines which forms and processes apply:

  • Commercial/Employer plans: Use standard UHC prior authorization forms
  • Individual/ACA marketplace plans: May require state-specific forms
  • Medicare Advantage: Different timelines and appeal rights
  • Medicaid (Community Plan): Electronic submission required as of December 2024
Note: Self-funded employer plans follow federal appeal rules only, not Pennsylvania's external review process.

Check your insurance card or member portal to identify your plan type. The UnitedHealthcare Provider Portal has plan-specific forms and policies.

Prior Authorization Forms & Requirements

Coverage Criteria for Tepezza

UnitedHealthcare's medical policy for Tepezza requires:

Requirement Details Documentation Needed
Diagnosis Moderate-to-severe thyroid eye disease (CAS ≥3) Ophthalmologist or endocrinologist diagnosis
Thyroid Status Euthyroid or levels within 50% of normal Recent TSH, free T3, free T4 (within 30 days)
Prior Treatment Failed corticosteroids or contraindication Chart notes documenting steroid trial/intolerance
Prescriber Board-certified specialist Ophthalmology or endocrinology credentials
Dosing FDA-approved regimen (8 infusions max) Treatment plan following label dosing

Required Documentation Checklist

Before submitting your prior authorization:

  • Completed UHC/OptumRx PA form for Tepezza
  • Recent thyroid function tests (TSH, free T3, free T4)
  • Clinical Activity Score (CAS) documentation
  • Photos showing proptosis or other TED features
  • Prior corticosteroid treatment records or contraindication notes
  • Specialist consultation notes
  • Treatment plan with HCPCS code J3241

Submission Portals & Methods

Online Submission (Fastest)

  1. UnitedHealthcare Provider Portal: Log in at UHCprovider.com and select "Prior Authorization and Notification tool"
  2. CoverMyMeds Integration: Submit through go.covermymeds.com/OptumRx for real-time determinations
  3. Upload all supporting documents as PDFs

Phone & Fax Options

  • OptumRx Prior Authorization Line: 1-800-711-4555 (Monday-Friday 5am-10pm PT, Saturday 6am-3pm PT)
  • Fax for non-urgent requests: 1-844-403-1027
  • Commercial plan general inquiries: 888-702-2202
Tip: Online submissions typically process faster than fax submissions and provide real-time status updates.

Specialty Pharmacy Setup

Tepezza must be dispensed through UnitedHealthcare's specialty pharmacy network, typically Optum Specialty Pharmacy.

Transfer Process

If you're switching from another specialty pharmacy:

  1. Contact Optum Specialty Pharmacy at 1-855-427-4682 (verify current number in your member portal)
  2. Provide your prescription information and previous pharmacy details
  3. Optum will coordinate the transfer and obtain necessary records
  4. Confirm your infusion center is in-network for administration

What to Expect

  • Prior authorization must be approved before Optum ships medication
  • Tepezza is billed under medical benefit using HCPCS code J3241
  • Medication ships to your infusion center, not your home
  • Typical infusion takes 60-90 minutes per visit

Appeals Process: Internal & Pennsylvania External Review

Step 1: Internal Appeal with UnitedHealthcare

If your Tepezza prior authorization is denied:

  • Timeline: File within 180 days of denial
  • Method: Submit through member portal, mail, or fax
  • Required: Address all denial reasons in your appeal letter
  • Decision: UHC has 15 business days for standard review, 72 hours for urgent cases

Step 2: Pennsylvania External Review

Pennsylvania residents with fully insured plans can appeal to an independent reviewer:

  • Eligibility: Fully insured commercial, ACA, and marketplace plans (not self-funded employer plans)
  • Timeline: Within 4 months (120 days) of UHC's final internal denial
  • How to file: Visit reviewmyclaim.pa.gov or call 1-877-881-6388
  • Decision: Binding decision within 45 days (expedited reviews within 72 hours)
  • Success rate: Approximately 50% of external appeals are overturned in favor of patients
Important: Pennsylvania's external review is free and binding. If overturned, UnitedHealthcare must provide coverage immediately and reimburse any out-of-pocket costs paid during the appeal.

Support Lines & Contacts

For Patients

  • UnitedHealthcare Member Services: Number on your insurance card
  • OptumRx Member Services: 1-855-427-4682
  • Pennsylvania Insurance Department Consumer Services: 1-877-881-6388

For Providers

  • UHC Provider Services: 888-702-2202
  • OptumRx Provider Line: 1-800-711-4555
  • Prior Authorization Status: Check via UHC Provider Portal

What to Ask When Calling

  • Specific denial reasons and required documentation
  • Timeline for resubmission
  • Whether expedited review is available
  • Status of pending prior authorization requests

Pennsylvania Consumer Protection Resources

Pennsylvania has strengthened patient protections for insurance appeals:

Pennsylvania Insurance Department

Additional Support

  • Pennsylvania Health Law Project: Provides free legal assistance for complex appeals
  • Pennie Consumer Hotline: For marketplace plan issues
  • Consumer Assistance Program: Free help with appeals, especially for low-income individuals

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and regulatory citations to maximize approval chances.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Plan criteria not met Submit updated clinical documentation showing CAS ≥3, specialist diagnosis Recent CAS assessment, specialist notes
Not euthyroid Provide recent thyroid labs showing levels within acceptable range TSH, free T3, free T4 within 30 days
No prior steroid trial Document previous corticosteroid treatment or medical contraindication Chart notes showing steroid trial failure or contraindication reasons
Inadequate documentation Resubmit with complete clinical records and photos Comprehensive medical records, TED progression photos
Coding errors Verify correct HCPCS code J3241 and dosing calculations Corrected billing with proper units

FAQ

How long does UnitedHealthcare prior authorization take in Pennsylvania? Standard review takes up to 15 business days; urgent cases are decided within 72 hours. Electronic submissions through the provider portal or CoverMyMeds typically process faster.

What if Tepezza is non-formulary on my plan? Tepezza is typically covered under the medical benefit (not pharmacy benefit) using HCPCS code J3241. If denied for formulary reasons, request a formulary exception with clinical justification.

Can I request an expedited appeal? Yes, if delay in treatment poses an immediate threat to your vision or health. Document the urgency in your appeal and request expedited review through both UnitedHealthcare and Pennsylvania's external review process.

Does Pennsylvania's external review apply to all UnitedHealthcare plans? No, only fully insured commercial, individual, and ACA marketplace plans. Self-funded employer plans are exempt from state external review and follow federal appeal processes only.

How much does Tepezza cost without insurance? Current wholesale cost is approximately $17,511 per 500mg vial. A full 8-infusion course can cost $350,000-$500,000+ depending on patient weight and dosing requirements.

What happens if I move out of Pennsylvania during treatment? Your appeal rights transfer to your new state's regulations. Contact your new state's insurance department for external review options and timelines.

If you're navigating a complex Tepezza denial, Counterforce Health can help build a comprehensive appeal strategy tailored to UnitedHealthcare's specific requirements and Pennsylvania's regulatory framework.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions. For personalized assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services or qualified legal advocates.

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