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Tzield® (Teplizumab-Mzwv) (for Pennsylvania Only)
Act
by Nov 1, 2026
Effective date
Nov 1, 2026
Identified
Oct 3, 2026
Summary
UnitedHealthcare Community Plan of Pennsylvania has revised coverage criteria for Tzield® (Teplizumab-Mzwv), a diabetes treatment drug. Key changes include: (1) adding a new requirement that clinical history must not suggest insulin resistance due to obesity, T2D, or other forms of diabetes; (2) removing the previous requirement to rule out T2D; and (3) clarifying lifetime treatment limits (one 14-dose course for stage 2 T1D patients; up to two 12-dose courses for stage 3 T1D patients aged 8-17). A new indication for pediatric stage 3 T1D patients was also added.
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What to do
by Nov 1, 2026 · 5 steps
01Billing and prior authorization teams must update internal systems and checklists to incorporate the new criteria requiring documentation that clinical history does NOT suggest insulin resistance due to obesity, T2D, or other forms of diabetes (remove the old requirement to rule out T2D).
02Update prior auth request templates to reflect two distinct indications: Stage 2 T1D (one 14-dose course lifetime) and Stage 3 T1D in ages 8-17 (up to two 12-dose courses lifetime).
03Ensure providers submitting Tzield requests for Pennsylvania Medicaid members include documentation of the specific clinical history assessment per revised criteria.
04Train prior authorization staff on the modified eligibility criteria to avoid claim denials.
05Update billing system notes to reflect that previous Tzield treatment history is a disqualifying factor.
If missed: Failure to apply updated criteria will result in claim denials and prior authorization rejections.
Codes mentioned
E10.10E10.11E10.21E10.22E10.29E10.311E10.319E10.3211E10.3212E10.3213E10.3219E10.3291E10.3292E10.3293E10.3299E10.3311E10.3312E10.3313E10.3319E10.3391E10.3392E10.3393E10.3399E10.3411E10.3412E10.3413E10.3419E10.349
Original notice
Tzield® (Teplizumab-Mzwv) (for Pennsylvania Only)
uhcprovider.com · Always check the source before changing claims.
Related changes
See all UnitedHealthcare changes →Tzield® (Teplizumab-Mzwv)MediumEffective Oct 1, 2026 · Medical Benefit Drug PolicyTzield® (Teplizumab-Mzwv)MediumEffective Oct 1, 2026 · Medical Benefit Drug PolicyTzield® (Teplizumab-Mzwv)MediumEffective Oct 1, 2026 · Medical Benefit Drug PolicyTzield® (Teplizumab-Mzwv)MediumEffective Oct 1, 2026 · Medical Benefit Drug PolicyBrowse every UnitedHealthcare change in the policy list
Related policy hubs
UnitedHealthcare policiesPA policy changesEndocrinologyPediatricsCode E10.10Code E10.11Code E10.21Code E10.22Code E10.29Code E10.311Code E10.319Code E10.3211Code E10.3212Code E10.3213Code E10.3219Code E10.3291Code E10.3292Code E10.3293Code E10.3299Code E10.3311Code E10.3312Code E10.3313Code E10.3319Code E10.3391Code E10.3392Code E10.3393Code E10.3399Code E10.3411Code E10.3412Code E10.3413Code E10.3419Code E10.349