CommercialPrior AuthMedium impact
Teprotumumab-trbw (Tepezza®)
BCBS Tennessee·TN · Ophthalmology, Endocrinology·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a new prior authorization policy for Teprotumumab-trbw (Tepezza®) for thyroid eye disease treatment, effective 10/31/26. Coverage is limited to one-time treatment course of 8 infusions for patients aged 18+ with moderate-to-severe disease who are euthyroid or have mild thyroid dysfunction, with documented glucocorticoid intolerance/failure/contraindication. Repeat infusion series are excluded. Does NOT apply to BlueCare plans.
Action Required
By October 31, 2026: Billing team must implement prior authorization requirements for Tepezza (J3241) claims. (1) Update billing system to require prior auth submission for all TED patients before claim processing. (2) Create PA checklist requiring: chart notes confirming moderate-to-severe disease, thyroid function labs (T3/T4 within normal limits or mild dysfunction <50% abnormal within 6 months), and documentation of glucocorticoid intolerance/failure/contraindication. (3) Ensure providers (ophthalmology and endocrinology consultation required) submit documentation with PA request. (4) Configure system to limit authorization to single 8-infusion course (1 initial 10mg/kg infusion + 7 maintenance 20mg/kg infusions every 3 weeks). (5) Update claim denial logic to reject repeat infusion series. (6) Verify patient age ≥18 before authorization. (7) Note exclusion: Do NOT apply policy to BlueCare plans. Claims submitted without prior auth or exceeding single-course limit will be denied.