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Independence Blue CrossCommercial · Coverage · Pharmacy · Ophthalmology, Endocrinology, PharmacyMedium impact

08.00.41b, Teprotumumab-trbw (Tepezza®)

Act
by Jan 6, 2025
Effective date
Jan 6, 2025
Identified
Jun 19, 2026

Summary

Independence Blue Cross updated policy 08.00.41b to 08.00.41c, expanding Tepezza coverage to include both active AND inactive moderate-to-severe thyroid eye disease (TED), removing the Clinical Activity Score requirement, and adding new criteria for patients with planned surgical ophthalmological intervention. Five additional ICD-10 diagnosis codes were added to support coverage determination.

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What to do

by Jan 6, 2025 · 7 steps
01Billing team must update authorization and claims submission protocols to reflect expanded coverage for Tepezza (J3241).
02Update prior authorization system to accept claims for BOTH active and inactive moderate-to-severe TED using the nine ICD-10 codes listed (E05.10, E05.20, E05.30, E05.80, E05.90, H05.831, H05.832, H05.833, H05.89).
03Remove requirement for Clinical Activity Score documentation from pre-authorization checklists.
04Add new criterion to prior auth forms: verify patient does NOT have planned surgical ophthalmological intervention for proptosis repair.
05Train billing and pre-auth staff on expanded coverage scope.
06Update denial reason codes—claims previously denied for inactive TED should now be re-reviewed for coverage eligibility.
07Notify providers (ophthalmologists and endocrinologists) of expanded criteria via bulletin.
If missed: Failure to implement will result in claim denials for previously non-covered inactive TED cases that now meet medical necessity criteria.

Codes mentioned

J3241E05.10E05.20E05.30E05.80E05.90H05.831H05.832H05.833

Original notice

08.00.41b, Teprotumumab-trbw (Tepezza®)
medpolicy.ibx.com · Always check the source before changing claims.
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Related policy hubs

Independence Blue Cross policiesOphthalmologyEndocrinologyPharmacyCode J3241Code E05.10Code E05.20Code E05.30Code E05.80Code E05.90Code H05.831Code H05.832Code H05.833

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