CommercialPrior AuthMedium impact
State and School Employees' Health Insurance Plan - Tepezza (teprotumumab-trbw)
Blue Cross & Blue Shield of Mississippi·MS · Endocrinology, Ophthalmology·Medical Policy
Effective date
Jul 1, 2023
We identified it
Jun 20, 2026
Summary
New medical policy establishes strict prior authorization requirements for Tepezza (teprotumumab-trbw) infusions for Thyroid Eye Disease under the State and School Employees' Health Insurance Plan. Coverage requires meeting multiple clinical criteria including active TED diagnosis, failed standard therapy, specialist consultation, and specific dosing limits with maximum 6-month approval.
Action Required
Immediately: Billing team must implement prior authorization requirements for all Tepezza (teprotumumab-trbw) infusions for State and School Employees' Health Insurance Plan members. Verify patients meet ALL criteria including age ≥18, active TED diagnosis with CAS ≥4, failed standard therapy, endocrinologist AND ophthalmologist consultation, and euthyroid status before scheduling infusions. Update system to track 8-infusion maximum with 6-month approval limit. Claims will be denied as cosmetic without proper authorization.