Provider Alert! New prior authorization requirements for Teprotumumab-trbw (Tepezza)

Attention: Ophthalmologists and Endocrinologists

Effective Date: January 19, 2021

Call to action: Texas Children’s Health Plan (TCHP) is aligning prior authorization criteria for teprotumumab-trbw (Tepezza), J3241 (formerly procedure code C9061), with the Texas Medicaid Provider Procedures Manual (TMPPM). Tepezza is a clinician administered drug indicated for members with thyroid eye disease (TED).

Below are the new prior authorization criteria for TCHP members effective 1/19/2021.

For initial therapy, ALL of the following criteria must be met:

• A diagnosis of Graves’ disease (diagnosis code E050) associated with active TED
• Active TED with a clinical activity score of 4 or greater
• Euthyroid, or the member has either mild hypothyroidism or mild hyperthyroidism
• No history of prior surgical intervention for TED and no plans of surgical treatment while on Tepezza

For this indication:

• Tepezza must be prescribed by, or in consultation with, an ophthalmologist or endocrinologist.
• Only for members 18 years old and older

Tepezza is not a benefit for:

• Pregnant members as it may potentially lead to fetal loss. Females of reproductive potential should use effective contraception prior to initiation, during treatment with Tepezza, and for 6 months after the last dose of Tepezza.

For renewal or continuation of therapy, ALL of the following criteria must be met:

• Previous treatment of Tepezza
• Member is not pregnant
• May not exceed the course of eight (8) total infusions per lifetime.

How this impacts providers: Providers should adjust their prescribing patterns accordingly and communicate these changes to their staff.

Next steps for providers: Prior authorization requests for J3241 must be submitted with a Special Medical Prior Authorization (SMPA) Request Form.  The completed Special Medical Prior Authorization (SMPA) Request Form must be maintained by the provider in the member’s medical record and is subject to retrospective review.  Providers should communicate these changes to their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.