Teprotumumab-trbw (Tepezza®)

By September 30, 2026: Billing and prior authorization teams must implement the following: (1) Billing system must be configured to require prior authorization for all Tepezza (teprotumumab-trbw) infusions for thyroid eye disease. (2) Prior auth submission requirements: Obtain supporting chart notes confirming moderate-to-severe TED disease severity per Appendix A criteria before approval. (3) Verify prescriber specialty: Only approve if prescribed by or in consultation with an ophthalmologist or endocrinologist; deny if prescribed by other specialties. (4) Quantity limit enforcement: System must cap authorization at ONE treatment course consisting of 8 infusions maximum (initial 10 mg/kg dose, then 20 mg/kg every 3 weeks for 7 additional doses). (5) Create internal denial protocol: Any claims for repeat Tepezza series must be denied with explanation that coverage does not include repeat treatment courses. (6) Provider communication: Alert all ophthalmology and endocrinology providers in network of coverage criteria and documentation requirements. Failure to implement these controls will result in claim denials and prior auth violations.