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Lumvoa ™ (Veligrotug-Vvze) and Tepezza® (Teprotumumab-Trbw) (for Pennsylvania Only)
Act
by Oct 31, 2026
Effective date
Nov 1, 2026
Identified
Oct 3, 2026
Summary
UnitedHealthcare Community Plan of Pennsylvania has updated coverage for two thyroid eye disease treatments (Lumvoa and Tepezza) effective November 1, 2026. The policy now covers both drugs under the same clinical criteria, adds new HCPCS billing codes (J3490, J3590), and establishes lifetime dose limits (5 doses for Lumvoa, 8 doses for Tepezza). Billing teams must implement prior authorization requirements and update systems to enforce these new limits.
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What to do
by Oct 31, 2026 · 9 steps
01Billing and prior authorization teams must.
02Update billing system to add HCPCS codes J3490 (Lumvoa) and J3590 (Tepezza) to the fee schedule for Pennsylvania Medicaid claims.
03Configure prior authorization rules to require prior auth for both drugs with mandatory verification of all clinical criteria including diagnosis of thyroid eye disease, disease severity staging, thyroid function status (euthyroid or mild hypo/hyperthyroidism), prescriber specialty (endocrinologist or ophthalmologist), and prior treatment history.
04Implement lifetime dose tracking functionality to enforce maximum 5 lifetime doses of Lumvoa and 8 lifetime doses of Tepezza per patient.
05Create or update PA Medicaid encounter forms/templates to include fields for documenting thyroid function levels (T3, T4), proptosis measurements, lid retraction measurements, soft tissue involvement status, diplopia presence, and any history of glucocorticoid intolerance/failure.
06Train providers that these drugs cannot be used in combination with other biologic immunomodulators (rituximab, tocilizumab, sarilumab, etc.).
07Notify all Pennsylvania Medicaid participating providers of the new coverage criteria and effective date.
08Claims submitted without prior authorization or exceeding lifetime dose limits will be denied.
09Claims for combinations with other biologic immunomodulators will be denied.
Codes mentioned
J3490J3590
Original notice
Lumvoa ™ (Veligrotug-Vvze) and Tepezza® (Teprotumumab-Trbw) (for Pennsylvania Only)
uhcprovider.com · Always check the source before changing claims.
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