By Counterforce Health Team in Tepezza (teprotumumab) —

Lowering Out-of-Pocket Costs for Tepezza (teprotumumab) with Blue Cross Blue Shield in California: Copay Cards, Appeals, and Financial Assistance

Answer Box: Getting Tepezza Covered at Lower Cost

Blue Cross Blue Shield California requires prior authorization for Tepezza (teprotumumab), but multiple cost-reduction strategies can help. The medication must be prescribed by an endocrinologist or ophthalmologist, with documented thyroid levels within 50% of normal limits. Fastest path: 1) Apply for Amgen's $0 copay program (commercial insurance only), 2) Request formulary exception if tier placement is high, 3) File internal appeal with clinical evidence if denied. California residents have strong Independent Medical Review rights after internal appeals. Start with your prescriber today to gather clinical documentation and submit prior authorization.

Table of Contents

What Drives Tepezza Costs

Tepezza's high cost stems from several factors that directly impact your out-of-pocket expenses. The medication costs approximately $17,511 per 500mg vial, with a full 8-infusion course often reaching $350,000-$500,000+ depending on patient weight and vial wastage.

Benefit Design Basics

Your Blue Cross Blue Shield plan structures Tepezza costs through:

  • Medical benefit coverage (not pharmacy benefit) using HCPCS code J3241
  • Prior authorization requirements before any administration
  • Formulary tier placement affecting your coinsurance percentage
  • Site of care restrictions that influence facility fees
  • Quantity limits based on FDA-approved dosing (maximum 3 vials for initial dose, 5 vials for subsequent doses)

Tiering Influences

Blue Cross Blue Shield typically places Tepezza on specialty tiers with 20-40% coinsurance. Even with insurance, patients may face $5,000-$15,000+ per infusion without additional assistance. Formulary placement varies by specific Blue Shield plan, making tier exceptions a critical cost-reduction strategy.

Investigating Your Benefits

Before starting treatment, gather specific information about your Blue Cross Blue Shield coverage to identify cost-reduction opportunities.

Information to Record

Call the member services number on your insurance card and ask:

  1. Formulary status: "Is Tepezza (teprotumumab, J3241) covered under medical benefits?"
  2. Tier placement: "What's my coinsurance percentage for specialty medications?"
  3. Prior authorization: "What clinical criteria must be met for approval?"
  4. Site of care: "Are there preferred infusion centers with lower facility fees?"
  5. Annual limits: "What's my out-of-pocket maximum for medical benefits?"
Tip: Request this information in writing via your member portal to reference during appeals.

Key Documents to Obtain

Manufacturer Copay Assistance

The Amgen By Your Side Copay Assistance Program offers the most significant cost reduction for commercially insured patients.

Eligibility and Benefits

Eligible patients can pay $0 for both medication and IV infusion costs. Requirements include:

  • Commercial insurance coverage (not Medicare, Medicaid, or other government programs)
  • U.S. or Puerto Rico residency
  • Age 18 or older
  • Program enrollment

How to Enroll

Contact Amgen By Your Side:

  • Phone: 1-833-469-8331 (Monday-Friday, 8 AM-8 PM ET)
  • Email: [email protected]
  • Fax: 833-469-8333

Once enrolled, you'll receive a dedicated Patient Access Liaison for one-on-one support throughout treatment. The program requires no proof of financial need.

Alternative Financial Assistance

For uninsured patients or those with government coverage, Amgen offers a separate Patient Assistance Program based on financial need. Additionally, organizations like Counterforce Health help patients navigate complex prior authorization requirements and appeals processes for specialty medications.

Formulary Exception Requests

If Tepezza is placed on a high-cost tier or faces utilization restrictions, formulary exceptions can reduce your financial burden.

Types of Exceptions Available

  • Tier exceptions: Request lower-tier cost-sharing
  • Quantity limit exceptions: Challenge dosing restrictions
  • Site of care exceptions: Request coverage for preferred infusion centers

Evidence Requirements

Your prescriber must provide:

  • Complete diagnosis documentation (thyroid eye disease with ICD-10 codes)
  • Clinical rationale for Tepezza over alternatives
  • Documentation of failed prior therapies or contraindications
  • Thyroid function test results showing levels within required ranges
  • Treatment goals and expected outcomes

Submission Process

Submit formulary exception requests within 72 hours of receiving prescriber documentation. Blue Cross Blue Shield must respond within 72 hours for standard requests.

Submission methods:

  • Fax: 1-877-378-4727
  • Online: Through Blue Shield member portal
  • Mail: To address specified on exception form

Pharmacy and Site of Care Choices

Your choice of infusion site significantly impacts total treatment costs beyond the medication price.

Approved Administration Sites

Blue Cross Blue Shield covers Tepezza administration in:

  • Office-based infusion
  • Freestanding infusion centers
  • Home infusion (with prior authorization)
  • Hospital outpatient facilities (requires additional prior authorization)

Cost Considerations

Hospital outpatient facilities typically carry higher facility fees but may be required if you:

  • Experience severe adverse reactions
  • Need additional clinical monitoring
  • Have complex medical conditions

Freestanding infusion centers often provide the most cost-effective option while maintaining clinical safety standards.

Coordination Tips

Work with your prescriber to:

  • Identify in-network infusion centers
  • Confirm prior authorization covers your preferred site
  • Understand facility fee structures
  • Coordinate scheduling for the 8-infusion series

California provides robust appeal rights through both internal insurer processes and state-supervised external review.

Internal Appeal Process

Step 1: Internal Appeal with Blue Cross Blue Shield

  • Submit within 180 days of denial
  • Include clinical documentation supporting medical necessity
  • Request expedited review for urgent situations (decision within 72 hours)

Step 2: Peer-to-Peer Review Request a clinical discussion between your prescriber and Blue Shield's medical director to clarify treatment rationale.

California Independent Medical Review (IMR)

If internal appeals fail, California residents can request Independent Medical Review through the Department of Managed Health Care (DMHC).

IMR Process:

  • File within 6 months of final internal denial
  • No cost to patients
  • Independent physician specialists review your case
  • Decision binding on Blue Cross Blue Shield
  • Standard IMR: 45 days; Expedited: 72 hours

Contact DMHC Help Center: 888-466-2219 or healthhelp.ca.gov

Note: While overall IMR success rates vary, cases with strong clinical evidence and specialist support have better outcomes.

Annual Renewal Planning

Plan ahead for potential changes that could affect your Tepezza coverage and costs.

What Can Change Annually

  • Formulary tier placement
  • Prior authorization criteria
  • Provider network changes
  • Copay assistance program terms
  • Out-of-pocket maximums

Renewal Reminders

  • Review Summary of Benefits changes each October
  • Confirm infusion center network status
  • Renew manufacturer copay assistance enrollment
  • Update clinical documentation if criteria change

Planning tip: If you're mid-treatment during open enrollment, confirm your current infusion center and prescriber remain in-network before switching plans.

Conversation Scripts

Calling Blue Cross Blue Shield Member Services

"Hi, I'm calling about coverage for Tepezza, also called teprotumumab, HCPCS code J3241, for thyroid eye disease. Can you tell me the prior authorization requirements, my coinsurance percentage, and approved infusion sites? I'd also like to know about formulary exception processes if the medication is on a high-cost tier."

Requesting Peer-to-Peer Review

"I'm requesting a peer-to-peer review for my patient's Tepezza prior authorization denial. The patient has documented thyroid eye disease with [specific symptoms], has failed [prior treatments], and meets all clinical criteria in your policy. When can we schedule a clinical discussion with your medical director?"

Pharmacy Coordination

"I need to coordinate Tepezza infusion scheduling. Can you confirm you have the medication in stock, verify my insurance authorization, and provide an estimate of my out-of-pocket costs after copay assistance? I'm also enrolled in the Amgen program."

FAQ

How long does Blue Cross Blue Shield prior authorization take in California? Standard prior authorization decisions are made within 5-14 business days. Expedited requests for urgent situations receive decisions within 72 hours.

What if Tepezza is non-formulary on my plan? You can request a formulary exception with clinical documentation. If denied, California's IMR process provides independent review of medical necessity determinations.

Can I use manufacturer copay assistance with any Blue Cross Blue Shield plan? The Amgen copay program works with commercial Blue Cross Blue Shield plans but cannot be combined with Medicare, Medicaid, or other government programs.

Does step therapy apply to Tepezza? Blue Shield's policy requires documentation of thyroid function control but doesn't mandate specific step therapy protocols for thyroid eye disease.

What happens if I move to a different state during treatment? Contact Blue Cross Blue Shield immediately to understand coverage changes. The Association operates independent plans by state with varying policies.

Can I request an expedited appeal? Yes, if delays in treatment could seriously jeopardize your health. California law requires expedited decisions within 72 hours for urgent situations.

From our advocates: We've seen patients successfully reduce Tepezza costs from $8,000+ per infusion to $0 by combining manufacturer copay assistance with formulary exceptions. The key is starting early—apply for financial assistance before your first infusion and gather all clinical documentation upfront. While the process takes persistence, California's strong consumer protection laws provide multiple appeal pathways when initial requests are denied.

Counterforce Health helps patients navigate complex prior authorization requirements and turn insurance denials into successful appeals for specialty medications like Tepezza. Our platform analyzes denial letters, identifies specific policy requirements, and drafts evidence-backed appeals that align with each insurer's criteria. Learn more about our services for getting specialty medications approved.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage determinations. For additional help with insurance appeals in California, contact the DMHC Help Center at 888-466-2219.

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