By Counterforce Health Team in Tepezza (teprotumumab) —

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

Answer Box: Getting Tepezza Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for Tepezza (teprotumumab-trbw, HCPCS J3241) under the medical benefit for moderate-to-severe thyroid eye disease (TED). Coverage criteria include Clinical Activity Score (CAS) ≥3, euthyroid status (TSH and free T3/T4 within 50% of normal), and documented corticosteroid failure or contraindication. Submit via the UHC Provider Portal with complete documentation for fastest processing (~15 business days). If denied, Washington residents can appeal internally within 180 days, then request external review through an Independent Review Organization (IRO) via the Washington State Insurance Commissioner.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Coverage Requirements at a Glance
  4. Gather What You Need
  5. Submit the Prior Authorization Request
  6. Follow-Up and Timelines
  7. If You're Asked for More Information
  8. If Your Request is Denied
  9. Washington State External Review Process
  10. Costs and Financial Assistance
  11. Quick Reference Checklist
  12. Frequently Asked Questions

What This Guide Covers

This guide helps Washington residents with UnitedHealthcare coverage navigate the prior authorization process for Tepezza (teprotumumab), a breakthrough treatment for thyroid eye disease. Whether you're a patient, caregiver, or healthcare provider, you'll find step-by-step instructions, required documentation, and state-specific appeal rights.

Tepezza is a fully human monoclonal antibody that targets IGF-1R receptors, reducing the inflammation and tissue changes that cause the debilitating symptoms of TED—bulging eyes, double vision, and eye pain. At approximately $17,511 per 500mg vial with a full course often exceeding $400,000, getting insurance approval is crucial.

Before You Start: Plan Verification

Confirm Your UnitedHealthcare Plan Type

Call UnitedHealthcare Member Services at 1-877-842-3210 to verify:

  • Plan type (commercial, Medicare Advantage, Medicaid)
  • Whether prior authorization is required for HCPCS code J3241
  • Your current deductible and coinsurance for medical benefits
  • In-network infusion center locations
Note: Tepezza is covered under the medical benefit (not pharmacy), administered at outpatient infusion centers.

Verify Provider Network Status

Ensure your ophthalmologist or endocrinologist is in-network. Out-of-network providers may face additional hurdles or require different authorization pathways.

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Diagnosis Moderate-to-severe active TED (CAS ≥3/7) Ophthalmologist exam notes, CAS breakdown, photos
Thyroid Status Euthyroid (TSH, free T3/T4 within 50% normal) Labs within 30 days
Prior Treatment Corticosteroid failure, intolerance, or contraindication Treatment records, doses, outcomes
Prescriber Board-certified ophthalmologist or endocrinologist Credentials verification
Dosing Maximum 8 lifetime infusions (10 mg/kg initial, then 20 mg/kg q3 weeks) Treatment plan
Age 18+ years Date of birth verification

Source: UnitedHealthcare Tepezza Policy

Gather What You Need

Essential Documentation

Clinical Records:

  • Complete ophthalmology consultation with CAS scoring
  • Serial photographs showing proptosis and lid retraction
  • Exophthalmometry measurements (proptosis in millimeters)
  • Visual field testing if applicable
  • Documentation of functional impact (diplopia, vision changes)

Laboratory Results:

  • TSH, free T3, free T4 (within 30 days, within 50% of normal limits)
  • TSI or TRAb levels if available
  • HbA1c if diabetic (Tepezza can worsen hyperglycemia)

Treatment History:

  • Records of corticosteroid trials (IV methylprednisolone or high-dose oral steroids)
  • Doses, duration, and reason for discontinuation
  • Documentation of contraindications (diabetes, hypertension, osteoporosis)
  • Any other TED treatments attempted (selenium, radiation therapy)

ICD-10 Codes for TED

  • H05.20 - Unspecified exophthalmos
  • E05.00 - Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
  • H05.21 - Displacement (lateral) of globe

Submit the Prior Authorization Request

Step-by-Step Submission Process

1. Provider Portal (Recommended)

  • Log into UHC Provider Portal
  • Navigate to Prior Authorization tool
  • Select HCPCS code J3241 (Tepezza)
  • Upload all required documentation
  • Submit electronically for fastest processing

2. Alternative: CoverMyMeds

  • Access via OptumRx portal
  • Complete electronic PA form
  • Attach clinical documentation

3. Fax Submission

  • Use plan-specific fax number (verify current number with UnitedHealthcare)
  • Include completed PA form and all supporting documents
  • Request fax confirmation receipt
Tip: Electronic submission through the provider portal typically processes faster than fax submissions.

Clean Request Packet Checklist

✓ Completed prior authorization form ✓ Clinical notes with CAS ≥3 documentation ✓ Recent thyroid function tests ✓ Corticosteroid treatment history ✓ Patient weight for dosing calculations ✓ Treatment plan (8 infusions maximum) ✓ Prescriber credentials and DEA number

Follow-Up and Timelines

Standard Processing Times

  • Standard review: 15 business days
  • Expedited review: 72 hours (if urgent medical need)
  • Medicare Advantage: May have shorter timelines per federal requirements

When to Follow Up

Call UnitedHealthcare Provider Services at 1-877-842-3210 if:

  • No response after 10 business days
  • Additional information is requested
  • You need to expedite for urgent medical reasons

Sample Follow-Up Script

"I'm calling to check the status of a prior authorization request for Tepezza (HCPCS J3241) submitted on [date] for patient [name]. The reference number is [if available]. Can you provide a status update and expected decision timeline?"

If You're Asked for More Information

UnitedHealthcare may request additional documentation to support medical necessity. Common requests include:

Medical Necessity Questions

  • More detailed CAS scoring: Provide point-by-point breakdown of all 7 CAS criteria
  • Functional impact documentation: Detailed description of how TED affects daily activities
  • Photographic evidence: Before/after photos showing disease progression
  • Specialist consultation: Additional ophthalmology or endocrinology opinions

Literature Support

Reference these authoritative sources in your medical necessity letter:

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Documentation to Add
CAS score insufficient Provide detailed CAS breakdown Point-by-point scoring with photos
Not euthyroid Optimize thyroid levels first Recent labs showing normal TSH/T3/T4
Inadequate steroid trial Document failure/contraindication Treatment records, adverse events
Missing clinical documentation Submit complete records All ophthalmology notes, labs, photos

Internal Appeal Process

First Level Appeal:

  1. Submit within 180 days of denial notice
  2. Include all original documentation plus additional evidence
  3. Write a detailed medical necessity letter addressing denial reasons
  4. Request peer-to-peer review with ophthalmologist or endocrinologist

Submit Appeals Via:

  • UHC Provider Portal (preferred)
  • Fax to appeals department
  • Certified mail to address on denial letter
From Our Advocates: In our experience helping patients with complex TED cases, the most successful appeals include comprehensive photo documentation showing disease progression and detailed functional impact statements. One patient's appeal was approved after including a letter from their employer documenting work limitations due to double vision—this concrete evidence of daily life impact can be compelling to reviewers.

Washington State External Review Process

If UnitedHealthcare denies your internal appeals, Washington residents have strong protections through the state's Independent Review Organization (IRO) process.

Eligibility and Filing

  • Available after exhausting internal appeals or if UnitedHealthcare exceeds processing timelines
  • Must file within 4 months of final internal denial
  • Applies to fully insured plans (most individual and small group plans)

How to Request External Review

  1. Submit written request to UnitedHealthcare describing the denial
  2. UnitedHealthcare forwards to certified IRO within 3 business days
  3. Provide additional information to IRO within 5 business days if desired
  4. IRO reviews all medical evidence and plan terms

Timelines

  • Standard review: IRO decision within 45 days
  • Expedited review: Decision within 72 hours if delay would jeopardize health

Contact Information

  • Washington State Insurance Commissioner: 1-800-562-6900
  • Online portal: insurance.wa.gov
  • Consumer assistance available for help navigating the process
Note: The IRO's decision is binding on UnitedHealthcare. If they overturn the denial, your insurer must provide coverage.

Costs and Financial Assistance

Manufacturer Support

Counterforce Health helps patients navigate complex prior authorization and appeal processes for specialty medications like Tepezza. Their platform analyzes denial letters and creates targeted, evidence-backed appeals that address specific payer criteria.

Amgen By Your Side Program:

  • Patient support services
  • Insurance verification assistance
  • Copay support for eligible patients
  • Phone: 1-833-AMGEN-1 (1-833-264-361)

Additional Resources

  • Patient Advocate Foundation: Copay relief program for qualifying patients
  • NeedyMeds: Database of patient assistance programs
  • Washington State Prescription Drug Program: May offer additional support for residents

Quick Reference Checklist

Before Submitting: □ Verify UnitedHealthcare plan type and PA requirements □ Confirm ophthalmologist/endocrinologist is in-network □ Gather all clinical documentation (CAS ≥3, photos, labs) □ Document corticosteroid trial or contraindication □ Ensure thyroid levels are within normal range

Submission: □ Use UHC Provider Portal for fastest processing □ Include complete documentation packet □ Request confirmation of receipt □ Note reference number for follow-up

Follow-Up: □ Check status after 10 business days □ Respond promptly to requests for additional information □ Prepare for potential peer-to-peer review

If Denied: □ File internal appeal within 180 days □ Address specific denial reasons with additional evidence □ Consider external review through Washington State IRO □ Contact Counterforce Health for appeals assistance

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take for Tepezza in Washington? A: Standard review is 15 business days. Expedited review (for urgent cases) is 72 hours. Submit via the provider portal for fastest processing.

Q: What if my thyroid levels aren't perfectly normal? A: UnitedHealthcare requires TSH and free T3/T4 within 50% of normal limits. Work with your endocrinologist to optimize levels before submitting the PA request.

Q: Can I get Tepezza if I haven't tried steroids? A: UnitedHealthcare requires documentation of corticosteroid failure, intolerance, or contraindication. If steroids are contraindicated due to diabetes or other conditions, document this clearly.

Q: What happens if I'm denied after internal appeals? A: Washington residents can request external review through an Independent Review Organization (IRO). This independent medical review is binding on UnitedHealthcare if they overturn the denial.

Q: Does step therapy apply to Tepezza? A: UnitedHealthcare does not impose formal step therapy for Tepezza, but requires prior corticosteroid trial documentation as part of medical necessity criteria.

Q: How many Tepezza infusions will UnitedHealthcare cover? A: Maximum 8 lifetime infusions per FDA labeling: one initial dose (10 mg/kg) followed by seven doses (20 mg/kg) every 3 weeks.

Q: What if my plan is self-funded? A: Self-funded employer plans follow federal ERISA rules and may not be subject to Washington state external review. Contact the U.S. Department of Labor for ERISA plan appeals guidance.

Sources and Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For personalized assistance with prior authorization and appeals, consider consulting with Counterforce Health, which specializes in turning insurance denials into successful, evidence-backed appeals.

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