By Counterforce Health Team in Tepezza (teprotumumab) —

Myths vs. Facts: Getting Tepezza (teprotumumab) Covered by Humana in New Jersey

Answer Box: Tepezza Coverage Facts for New Jersey Humana Members

Myth-busting reality: Tepezza (teprotumumab) requires prior authorization through Humana Medicare Advantage in New Jersey, but approval is possible with proper documentation. Key facts: Submit PA via Humana Clinical Pharmacy Review (800-555-2546), include Clinical Activity Score ≥4, thyroid labs ≤30 days, and prior therapy records. If denied, New Jersey's IHCAP external review through Maximus Federal Services provides binding decisions within 45 days. Start today: Log into MyHumana to verify formulary status and download the PA form.

Table of Contents

Why Tepezza Coverage Myths Persist

Thyroid Eye Disease patients in New Jersey face a maze of conflicting information about getting Tepezza (teprotumumab) covered by Humana. At around $350,000-$500,000 for a full treatment course, the stakes couldn't be higher—yet myths and outdated advice often derail legitimate coverage requests.

The confusion stems from several sources: Tepezza's relatively recent FDA approval (2020), evolving payer policies, and the complexity of Medicare Advantage rules that vary by state. Many patients receive advice based on other insurers' policies or outdated criteria, leading to unnecessary denials and delayed treatment.

Counterforce Health helps patients navigate these challenges by analyzing denial letters and crafting evidence-backed appeals that align with each payer's specific requirements. Understanding the facts—not the myths—is your first step toward successful coverage.

Top 8 Myths About Humana Tepezza Coverage

Myth 1: "If my ophthalmologist prescribes Tepezza, Humana has to cover it"

Fact: Prescription alone doesn't guarantee coverage. Humana requires prior authorization for all Tepezza requests, regardless of prescriber specialty. The PA must demonstrate medical necessity through specific clinical criteria, including Clinical Activity Score (CAS) ≥4, documented thyroid eye disease progression, and evidence of prior therapy failures or contraindications.

Myth 2: "Tepezza is automatically covered under my pharmacy benefit"

Fact: Tepezza is covered under the medical benefit (Part B for Medicare Advantage), not pharmacy. It uses HCPCS code J3241 for physician-administered infusions. Submitting pharmacy claims will result in automatic denials. Your infusion center handles the billing, not your retail pharmacy.

Myth 3: "I need to try steroids for 6 months before Humana will approve Tepezza"

Fact: While prior therapy documentation is required, there's no mandated 6-month steroid trial. Humana's criteria accept evidence of steroid failure, intolerance, or contraindications. Diabetic patients with contraindications to high-dose steroids can often bypass this requirement with proper documentation.

Myth 4: "My thyroid levels have to be perfect for approval"

Fact: Humana requires "euthyroid status," defined as thyroid function tests within 50% of the reference range—not perfect normal values. Recent labs (≤30 days) showing TSH, T3, and T4 within this range typically satisfy the requirement, even if not completely normalized.

Myth 5: "Appeals never work for expensive drugs like Tepezza"

Fact: New Jersey's external review system has robust protections. IHCAP reviews through Maximus Federal Services are binding on insurers and decided by independent physicians. Nationally, external reviews favor patients in approximately 50% of cases when proper medical evidence is submitted.

Myth 6: "I can only get Tepezza at the hospital"

Fact: Humana covers Tepezza at various sites of care, including physician offices, ambulatory infusion centers, and hospital outpatient departments. The key is using an in-network provider and obtaining PA approval before the first infusion. Site of care affects facility fees but not drug coverage.

Myth 7: "If I'm denied once, I can't reapply"

Fact: You can resubmit PA requests with additional documentation, appeal through Humana's internal process, and ultimately request external review through New Jersey's IHCAP program. Each level provides new opportunities to present evidence and address the specific denial reasons.

Myth 8: "Medicare Advantage plans like Humana can't deny FDA-approved drugs"

Fact: Medicare Advantage plans have significant latitude to require prior authorization, step therapy, and medical necessity documentation for expensive specialty drugs. Humana's PA denial rate is approximately 3.5%, among the lowest of major insurers, but denials do occur when criteria aren't met.

What Actually Influences Approval

Clinical Documentation Requirements

Successful Tepezza approvals hinge on specific clinical evidence:

Requirement Acceptable Evidence Source
TED Diagnosis ICD-10 codes H05.20-H05.29, ophthalmology notes Tepezza Clinical Documentation Guide
Disease Activity Clinical Activity Score (CAS) ≥4 or documented progression Stanford TED Guidelines
Thyroid Status TSH, T3, T4 within 50% of reference range (≤30 days) Humana PA Policy
Prior Therapy Steroid trial records or contraindication documentation Humana Coverage Policies
Prescriber In-network ophthalmologist or endocrinologist preferred Humana Provider Network

Administrative Factors

Beyond clinical criteria, these operational elements affect approval:

  • Timing: Submit PA 2-3 weeks before planned treatment start
  • Completeness: Include all required forms, labs, and clinical notes in initial submission
  • Network Status: Verify prescriber and infusion site are in-network
  • Coding: Ensure proper J3241 billing setup with your infusion center

Avoid These 5 Critical Mistakes

1. Incomplete Clinical Activity Score Documentation

The Error: Submitting PA requests without a complete 7-point or 10-point CAS assessment.

The Fix: Ensure your ophthalmologist documents all CAS components: spontaneous retrobulbar pain, pain on gaze, eyelid redness, conjunctival redness, eyelid swelling, caruncle inflammation, and chemosis. Include numerical scores and exam photos when possible.

2. Outdated Thyroid Function Tests

The Error: Including lab results older than 30 days.

The Fix: Obtain fresh TSH, T3, and T4 levels within 30 days of PA submission. If levels are outside the acceptable range, work with your endocrinologist to optimize therapy before resubmitting.

3. Vague Prior Therapy Documentation

The Error: Simply stating "patient tried steroids" without specifics.

The Fix: Document exact medications, doses, duration, and outcomes. For example: "Prednisone 80mg daily x 2 weeks, tapered over 8 weeks. Patient experienced minimal improvement in proptosis (22mm to 21mm OD) with significant hyperglycemia requiring insulin initiation."

4. Wrong Benefit Category Submission

The Error: Submitting Tepezza requests through pharmacy channels.

The Fix: Work with your infusion center to submit medical benefit claims using J3241. Ensure they have PA approval before scheduling infusions.

5. Missing Appeal Deadlines

The Error: Waiting too long to appeal denials.

The Fix: File internal appeals within 65 days of denial notice. Track deadlines carefully—New Jersey allows external review within 180 days of final internal denial.

Your 3-Step Action Plan

Step 1: Verify Coverage and Requirements (Today)

  1. Log into MyHumana to check your plan's formulary status for Tepezza
  2. Download current PA forms and requirements
  3. Verify your ophthalmologist and preferred infusion center are in-network
  4. Call Humana Clinical Pharmacy Review at 800-555-2546 to confirm current PA criteria

Step 2: Gather Complete Documentation (This Week)

Clinical Records Needed:

  • Complete ophthalmology exam with CAS scoring
  • Thyroid function tests (TSH, T3, T4) within 30 days
  • Prior therapy records with specific outcomes
  • High-quality orbital photos (if available)
  • Proptosis measurements and visual field testing

Administrative Documents:

  • Insurance cards and member ID
  • Completed Humana PA form
  • Prescriber NPI and specialty verification
  • Infusion center network confirmation

Step 3: Submit and Track (Next Week)

  1. Submit complete PA packet via Humana provider portal or fax
  2. Request confirmation of receipt and reference number
  3. Follow up every 3-5 business days for status updates
  4. If denied, immediately begin appeal preparation while deadline clock is ticking
From Our Advocates: We've seen the strongest Tepezza approvals include before-and-after photos showing disease progression, detailed steroid trial documentation with specific doses and side effects, and letters from both ophthalmology and endocrinology explaining why Tepezza is the appropriate next step. The key is painting a complete clinical picture that addresses each PA criterion directly.

New Jersey External Review Process

If Humana denies your Tepezza request after internal appeals, New Jersey's Independent Health Care Appeals Program (IHCAP) provides a final avenue for coverage.

IHCAP Process Through Maximus Federal Services

Eligibility: Completed Humana's internal appeal process; denial based on medical necessity (not contract exclusions)

Timeline: Submit within 180 days of final internal denial

Process:

  1. Submit Appeal: File with Maximus Federal Services (New Jersey's contracted IURO)
  2. Preliminary Review: Maximus confirms eligibility within 5 business days
  3. Medical Review: Independent physicians evaluate medical necessity using submitted records and clinical guidelines
  4. Decision: Standard appeals decided within 45 days; expedited appeals within 48 hours for urgent cases
  5. Implementation: If overturned, Humana must provide coverage within 10 business days

Cost: Free to patients; insurers pay all IURO fees

Contact: IHCAP Hotline at 1-888-393-1062 for assistance with forms and process

FAQ: Common Questions

Q: How long does Humana prior authorization take for Tepezza in New Jersey? A: Standard PA decisions typically take 15-30 days. Expedited requests (for urgent medical situations) may be processed within 72 hours. Track status through the Humana provider portal or member services.

Q: What if Tepezza isn't on Humana's formulary? A: Tepezza is typically covered under the medical benefit (J3241), not pharmacy formulary. If your plan excludes it entirely, you can request a formulary exception based on medical necessity and lack of therapeutic alternatives.

Q: Can I appeal if my ophthalmologist is out-of-network? A: Yes, but you'll need to demonstrate either lack of in-network specialists with TED expertise or geographic access barriers. Include a network exception request with your PA submission.

Q: Does step therapy apply to Tepezza in New Jersey? A: Humana may require documentation of prior corticosteroid therapy or contraindications. This isn't always a strict step therapy requirement—contraindications due to diabetes, psychiatric conditions, or previous adverse reactions can satisfy this criterion.

Q: What happens if I need Tepezza urgently for sight-threatening complications? A: Request expedited PA review and, if denied, file an expedited external appeal through IHCAP. Sight-threatening conditions like compressive optic neuropathy qualify for accelerated review timelines.

Q: Can my doctor request a peer-to-peer review with Humana? A: Yes, prescribers can request peer-to-peer consultations with Humana medical directors. This often resolves coverage issues when clinical nuances need direct physician discussion.

Resources and Next Steps

Humana Resources:

New Jersey State Resources:

Clinical Resources:

Patient Support:

  • Amgen By Your Side: Patient assistance programs and copay support
  • Thyroid Eye Disease Foundation: Educational resources and advocacy

For complex denials or appeals requiring detailed medical evidence analysis, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals that align with payer-specific requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For official New Jersey insurance regulations and consumer rights, visit the New Jersey Department of Banking and Insurance.

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