CareCost Prior authorization
Required
Check what the payer requires before you schedule Tepezza.
Prior authorization · diagnosis documentation · glucocorticoids at some payers · one course per lifetime
28 payer policy sets · source-linked · reviewed August 2026
Aetna + Thyroid eye disease is shown as a live example until you choose a payer.
This payer requires an approval on file before Tepezza is purchased or infused for this member.
Precertification of teprotumumab-trbw (Tepezza) is required of all Aetna participating providers and members in applicable plan designs.
Covered under ICD-10 H05.24.
medically necessary for the treatment of thyroid eye disease (TED) when all of the following criteria are met
The policy names the dose and frequency it pays for.
10mg/kg on first infusion, followed by 20mg/kg every 3 weeks for 7 additional infusions
What opens in CareCost
Aetna · Tepezza · Thyroid eye disease
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Tepezza · Thyroid eye disease
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Tepezza coverage requirements across 28 payer policy sets.
Aetna · Anthem / Elevance · UnitedHealthcare · Cigna · Premera · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →22 of 28 commercial payers require prior authorization, across 225 rules, and 6 of the remaining approvals turn on named clinical criteria rather than a bare authorization request. Tepezza has one FDA indication, so the corpus varies by documentation depth and course strictness rather than by diagnosis.
22 require PA · 27 apply a clinical prerequisite · 9 restrict site of care · no payer names a preferred teprotumumab-trbw product
22 of the 28 payers in CareCost’s teprotumumab corpus flag a formal approval requirement before the drug is purchased or infused. The other 6 — HCSC, BCBS Louisiana, BCBS South Carolina, Horizon, Independence and UnitedHealthcare — carry no separate flag but still apply the same criteria before paying.
Every payer in the corpus points to the same H05.24 exophthalmos family (H05.241–H05.249 by eye, a category code with a laterality digit): thyroid eye disease, regardless of activity or duration. 30 rules across all 28 payers name it, with no second diagnosis to split against.
Coverage turns on measured disease activity, not the diagnosis code alone. Anthem requires “Proptosis ≥ 3 mm above normal values for race and sex”; Florida Blue requires “active TED as confirmed by a baseline Clinical Activity Score (CAS) of 3 or greater (on the 7-item scale) in the more severely affected eye”; BCBS Minnesota requires a “Clinical Activity Score (CAS) ≥ 4”; BCBS Michigan requires “Euthyroid function with free triiodothyronine (T3) and thyroxine (T4) within the normal limits for the range of the laboratory.” Aetna adds a specialist and an age floor: “This medication must be prescribed by or in consultation with an ophthalmologist or endocrinologist” and “Member is 18 years of age or older.” Two payers add a counseling step: BCBS South Carolina requires “Attestation that the patient is not pregnant and been informed that appropriate forms of contraception should be implemented prior to initiation, during treatment and for 6 months following the last dose of Teprotumumab-trbw,” and BCBS Michigan requires “Physician attestation a discussion has been had with the member to stop smoking if they are a current smoker.”
12 of the 28 payers require a documented steroid trial before Tepezza, not a competing biologic. Florida Blue: “had an inadequate response to, had intolerable adverse effects with, or has a contraindication to at least a 6-week treatment course of high-dose IV glucocorticoids”; BCBS Michigan: “Treatment with an adequate course of oral or intravenous (IV) corticosteroids (for example 30 mg/day prednisone for 4 weeks) has been ineffective, not tolerated, or is contraindicated”; Regence: “Treatment with an adequate course of intravenous glucocorticoids (IVGC) has been ineffective after at least 6 weeks, not tolerated, or is contraindicated”; UnitedHealthcare: “History of intolerance, failure, or contraindication to oral or intravenous glucocorticoids (e.g., prednisone, methylprednisolone)”; Centene: “Failure of a 4-week trial of a systemic corticosteroid (at up to maximally indicated doses), unless one of the following (a, b, or c)”. The remaining 16 payers require only the diagnosis and course documentation above.
19 rules converge on the same regimen as the label. Aetna states it directly: “10mg/kg on first infusion, followed by 20mg/kg every 3 weeks for 7 additional infusions.” Regence ties the same regimen to its course limit: Tepezza “will be approved for up to a total of eight infusions (one treatment course) per lifetime, based on dosing of up to a maximum of 20 mg/kg/dose every three weeks.”
The 23 quantity-limit rules cap the course at eight infusions, several of them per lifetime, framed by several payers as a one-time benefit rather than an annual one. Florida Blue: “Approval duration: 6 months to allow for 8 total infusions (and not to exceed 8 life-time doses).” BCBS Kansas covers Tepezza “for one course of therapy per lifetime,” and BCBS South Carolina documents the identical limit in its own policy. BCBS Louisiana considers “the use of nine or more doses of teprotumumab-trbw (Tepezza) to be investigational.” BCBS Nebraska limits the drug to “38 vials/lifetime.” BCBS Minnesota and Capital BlueCross both cap units at “150 billable units initially followed by 250 billable units every 3 weeks for 7 additional doses.”
Two payers say a Tepezza approval does not renew. BCBS Michigan: “Renewal Criteria: Not applicable as no further authorization will be provided.” Capital BlueCross: “Renewal: Prior authorization validity may NOT be renewed.*” A repeat course, where addressed, is a medical-policy exception rather than a renewal review.
BCBS Tennessee, HMSA and HCSC each treat the lifetime limit as a hard bar rather than a quantity cap: BCBS Tennessee, “Coverage will not be provided for repeat series of Tepezza infusions”; HMSA, the same wording; HCSC calls a repeat course “experimental, investigational, and/or unproven…when used as a repeat course of treatment (beyond the initial 8 doses).” BCBS Louisiana and Regence both exclude surgery candidates: BCBS Louisiana requires the patient has “NOT had prior surgical treatment or orbital irradiation for Thyroid Eye Disease and is NOT planning” either during treatment; Regence requires “No prior surgical treatment for thyroid eye disease.” BCBS South Carolina separately excludes recent vision loss from optic neuropathy. Regence also carries a not-covered rule for cosmetic use: Tepezza “for less severe thyroid eye disease without proptosis resulting in a significant medical complication is considered cosmetic…and not coverable.”
9 payers restrict the infusion site, across 10 rules. Aetna: “Site of Care Utilization Management Policy applies for teprotumumab-trbw (Tepezza).” Florida Blue: “If teprotumumab (Tepezza) is administered in a hospital-affiliated outpatient setting, additional requirements may apply depending on the member’s benefit.” Highmark allows administration “in a physician’s office not affiliated with a hospital, specialized infusion centers not affiliated with a hospital or in the home” and separately calls an unapproved hospital outpatient setting “not medically necessary…when an approved site of care is a viable option for treatment.” Premera: “Tepezza (teprotumumab-trbw) is subject to review for site of service administration.” HCSC, BCBS Michigan, Cigna, Regence and Blue Shield of California also restrict site of care.
Tepezza’s 28-payer corpus converges on a different shape than a step-therapy drug: measured disease activity, a steroid trial at some payers, and eight infusions the corpus treats as a one-time benefit.
| Requirement | What the corpus documents | Basis |
|---|---|---|
| Documented active diagnosis | Proptosis ≥ 3 mm above normal values for race and sex, or a Clinical Activity Score of 3 or 4 or more, plus euthyroid labs | Clinical-prerequisite rules, 102 of 225, across 27 of 28 payers |
| Glucocorticoids first | An inadequate response to, intolerance of, or contraindication to a course of oral or IV glucocorticoids, before Tepezza rather than a competing biologic | 12 of 28 payers |
| One course per lifetime | Eight infusions, not to exceed 8 lifetime doses; a ninth or a repeat series is investigational, not covered, or excluded outright | Quantity-limit rules, 23 total; contraindication-exclusion rules, 11 total |
| No renewal on file | BCBS Michigan and Capital BlueCross both state the authorization is not renewable | Reauthorization rules, 2 of 28 payers |
| Preferred teprotumumab-trbw product | None named — no biosimilar and no same-class J-coded alternative exists in this corpus | Preferred-product rules, 0 of 28 payers |
Tepezza is a standard Medicare Part B buy-and-bill drug, priced off the ASP-based fee schedule under J3241 for the FDA-labeled indication below; see the cost estimate for the current rate and the 20% coinsurance after the Part B deductible. Medicare coverage follows Part B buy-and-bill rules: a covered diagnosis, medical necessity, and a claim coded to thyroid eye disease. Tepezza has no biosimilar and no same-class J-coded alternative, so this is the only code Medicare pays for the drug under.
It depends on the payer and plan. In CareCost’s teprotumumab corpus, 22 of 28 commercial payers require prior authorization, and coverage turns on documented thyroid eye disease activity and a lifetime course limit rather than a sequence of step-therapy trials. Check this patient’s payer →
Most Tepezza (J3241) policies start with the same core: a thyroid eye disease diagnosis under the H05.24 exophthalmos family (H05.241–H05.249 by eye), proptosis or Clinical Activity Score documentation, and confirmation this is a first course. At 12 of 28 payers a glucocorticoid trial is required first, and no payer names a preferred teprotumumab-trbw product. CareCost turns the applicable policy into a patient-level checklist, each item with the exact policy language behind it. Open patient clearance →
Yes. Original Medicare pays for Tepezza under Part B as a physician-administered biologic, billed under J3241 and priced off the ASP-based fee schedule. See the cost estimate →
At 12 of 28 payers. Florida Blue requires an inadequate response to, intolerable adverse effects with, or a contraindication to at least a 6-week course of high-dose IV glucocorticoids; Regence requires an adequate course of intravenous glucocorticoids to have failed after at least 6 weeks; UnitedHealthcare and Centene document the same pattern. The remaining 16 payers document the diagnosis and course limit without a glucocorticoid trial. Check this patient’s payer →
One course, almost everywhere. Tepezza is eight infusions — 10 mg/kg first, then 20 mg/kg every 3 weeks for seven more — and CareCost’s corpus treats a second course as an exception rather than a renewal: BCBS Kansas and South Carolina cover one course of therapy per lifetime, BCBS Louisiana calls nine or more doses investigational, and BCBS Michigan and Capital BlueCross write that the authorization may not be renewed. Check this patient’s payer →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and specialty-drug policies · prior-authorization criteria · site-of-care policies · clinical-prerequisite criteria. Medicare coverage follows Part B buy-and-bill rules, priced off the ASP-based fee schedule. Every CareCost requirement links back to its source policy.