Medicare AdvantagePrior AuthMedium impact
Tepezza® (teprotumumab) (Revised)
Humana·KY, SC · Ophthalmology, Endocrinology·Medicaid
Effective date
Feb 25, 2026
We identified it
Jun 25, 2026
Summary
Humana has revised its Tepezza (teprotumumab) pharmacy coverage policy effective February 25, 2026, for Medicare and Medicaid members in Kentucky and South Carolina. The policy maintains prior authorization requirements with five specific clinical criteria, including diagnosis confirmation, euthyroid status, specialist prescribing requirement, lifetime infusion limits (8 infusions), and documented moderate-to-severe thyroid eye disease. No billing codes are specified in this policy document.
Action Required
By February 25, 2026: Billing and prior authorization teams must ensure systems enforce all five approval criteria for Tepezza prior authorization requests in Kentucky and South Carolina Medicaid and Medicare plans. Specifically: (1) Verify thyroid eye disease diagnosis, (2) Confirm member is euthyroid or receiving thyroid treatment, (3) Validate prescriber is ophthalmologist/endocrinologist/thyroid specialist, (4) Confirm member has not exceeded 8 lifetime infusions, and (5) Document moderate-to-severe disease (≥2mm lid retraction, moderate/severe soft tissue involvement, ≥3mm exophthalmos, or diplopia). Update prior authorization request forms and clinical review templates to capture all five criteria. Train clinical reviewers on hearing assessment requirements before, during, and after treatment, plus monitoring for infusion reactions, IBD exacerbation, and hyperglycemia per warnings. Failure to apply all criteria will result in claim denials and potential member appeals.