CurrentHawaii Medical Service Association (HMSA)Policy N/A

Tepezza (teprotumumab) prior authorization for thyroid eye disease

Prior authorization request form for Tepezza (teprotumumab) under the patient's prescription benefit plan managed by CVS Caremark; defines required clinical information, documentation, and contact/fax for authorization decisions.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyTepezza (teprotumumab) prior authorization for thyroid eye disease

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization from CVS Caremark (fax 1-866-237-5512) and attach supporting chart notes documenting moderate-to-severe thyroid eye disease and objective findings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8treatment course

18+min age

≥3 mmexophthalmos

≥2 mmlid retraction

Coverage Criteria for Teprotumumab (Tepezza)

Authorization criteria checkpoints

Authorization proceeds when required clinical checkpoints are documented.

Primary diagnosis: Patient has diagnosis of thyroid eye disease (TED)

If other diagnosis, follow Criteria Exception Policy

Prescriber involvement: Medication prescribed by or in consultation with an ophthalmologist

Yes/No captured on form

Prior exposure: Documentation whether patient previously received the requested medication

Yes/No captured on form

Severity assessment:

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyTepezza (teprotumumab) prior authorization for thyroid eye disease

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization from CVS Caremark (fax 1-866-237-5512) and attach supporting chart notes documenting moderate-to-severe thyroid eye disease and objective findings.

SourceLink

On This Page

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The form makes clear that authorization depends on documented clinical checkpoints; when the required severity, age, or dosing parameters are not met or are not documented, the request may not be supported. Specifically, absence of documentation of moderate‑to‑severe disease, failure to meet the minimum age of 18 years, or exceeding the one‑time treatment course of 8 infusions (10 mg/kg first infusion, then 20 mg/kg every 3 weeks for seven additional infusions) are all queried on the form and may lead to non‑approval if supporting records are not provided. Submitters should attach chart notes or medical records showing the required findings to avoid denial.

Diagnosis and Clinical Thresholds / Coding

Requested diagnosis codeICD-10

ICD-10

Form requests the applicable ICD-10 diagnosis code (not specified on form)

inv-05: Exophthalmos threshold — ≥ 3 mm above normal for race and gender

Exophthalmos threshold≥ 3 mm above normal for race and gender

Clinical contextListed as one of the objective findings that qualifies under clinical findings for TED

Action if presentSelect on form to continue authorization workflow (Continue to #7)

inv-06: Lid retraction threshold — ≥ 2 mm

Lid retraction threshold≥ 2 mm

Clinical roleListed as an objective finding used to establish disease severity for TED

Form actionSelect on form to continue authorization workflow (Continue to #7)

inv-07: Age threshold — ≥ 18 years

Minimum age≥ 18 years

Form checkpointQuestion #7 asks if patient is 18 years of age or older to proceed

Effect on authorizationAge must be documented; selection directs continuation of authorization workflow

Provider Requirements and Prior Authorization Process

Prior Authorization

Prior Authorization Requirement

Prior Authorization Required: Prior authorization is required for coverage. Submit requests to CVS Caremark (fax 1-866-237-5512). For questions about prior authorization determinations contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care / eligibility, copay, or medication delivery questions contact CaremarkConnect at 1-800-237-2767. Approvals may be subject to dosing limits consistent with FDA labeling, accepted compendia, and evidence-based guidelines.

Fax prior authorization requests to CVS Caremark: 1-866-237-5512
Phone for PA questions: 1-808-254-4414
Specialty Customer Care (eligibility/cost/delivery): 1-800-237-2767

Documentation Required

Documentation-Dependent Authorization

Authorization decisions depend on receiving complete and accurate clinical documentation. Missing, incomplete, or inaccurate documentation may delay review or result in denial of the request. Attach supporting chart notes or medical records that demonstrate the clinical assessments and findings used to establish disease severity and eligibility.

Ensure chart notes/medical records supporting moderate-to-severe disease assessment are included
Incomplete forms or missing attachments can delay or prevent authorization

Note

Administrative and Demographic Information

Include administrative and demographic details on the PA form and supporting submission: patient identifiers and contact information, patient weight (kg) and height (inches), ICD-10 diagnosis code, where the drug will be dispensed (e.g., pharmacy, office, outpatient hospital) and where it will be administered (e.g., infusion center, home, office, inpatient), and prescriber information (name, specialty, NPI, office phone, office fax).

Patient name, ID, DOB, phone
Patient weight (kg) and height (inches)
ICD-10 code for indication
Dispensing site and administration site selection (office, pharmacy, outpatient hospital, home, etc.)
Prescriber name, specialty, NPI, office phone, office fax

Note

Prior Medication Check

Document prior medication exposure: indicate whether the patient has previously received the requested medication. Record prior use on the PA form — this documents treatment history but does not by itself mandate trial of an alternative therapy.

State if patient has previously received the requested medication (Yes/No)
Provide dates and relevant clinical response if available

Key Definitions and Treatment Course

inv-14: Moderate-to-severe disease — clinical assessment category prompting attachment of supporting chart notes; no numeric scale provided in form

DefinitionClinical assessment category prompting attachment of supporting chart note(s) or medical record indicating moderate-to-severe disease assessment

Form requirementIf 'Yes' to moderate-to-severe disease, ACTION REQUIRED: attach supporting chart note(s) or medical record

No numeric scale providedThe form requests documentation but does not supply a numeric severity scale

inv-15: One-time treatment course — 8 infusions every 3 weeks (10 mg/kg first, then 20 mg/kg x7)

One-time treatment course8 infusions given once every 3 weeks (10 mg/kg first infusion, followed by 20 mg/kg every 3 weeks for 7 additional infusions)

Form checkpointQuestion #8 asks whether the patient exceeds this one-time treatment course

Authorization consequenceSelection documents whether dosing limits consistent with the one-time course have been met or exceeded

Background

Tepezza (teprotumumab) is authorized for treatment of thyroid eye disease (TED); the prior authorization form collects clinical indicators to document disease severity and activity. The form requires an assessment of whether the patient has moderate‑to‑severe disease and requests attachment of supporting chart notes or medical records when “Yes” is selected. It also captures specific objective findings that support severity, including lid retraction ≥ 2 mm, moderate or severe soft‑tissue involvement, exophthalmos ≥ 3 mm above normal for race and gender, and inconstant or constant diplopia. In addition, the form queries disease activity (active vs inactive) and documents prior exposure to the medication and whether the patient meets the single course dosing limit of 8 infusions (10 mg/kg first infusion, then 20 mg/kg every 3 weeks for 7 additional infusions).