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Independence Blue CrossMedicare Advantage · Coverage · Pharmacy · Ophthalmology, Endocrinology, PharmacyMedium impact

MA08.115b, Teprotumumab (Tepezza®)

Effective date
Jan 6, 2025
Identified
Jun 19, 2026

Summary

Independence Blue Cross updated MA08.115b to MA08.115c, expanding Tepezza (teprotumumab-trbw) coverage to include both active AND inactive moderate-to-severe thyroid eye disease (TED), removing the Clinical Activity Score requirement, and adding new exclusion criteria for planned surgical ophthalmological intervention. Five new ICD-10 codes for thyrotoxicosis have been added as medically necessary diagnoses.

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What to do

Action · 7 steps
01Before January 6, 2025.
02Billing team must update claims submission system to recognize the five newly added ICD-10 codes (E05.10, E05.20, E05.30, E05.80, E05.90) as medically necessary for Tepezza coverage.
03Update prior authorization workflows to remove Clinical Activity Score documentation requirement and instead verify presence of moderate-to-severe TED symptoms per the revised criteria.
04Add validation rule to reject claims where patient has documented planned surgical ophthalmological intervention for proptosis repair—contact providers to confirm no planned surgery before processing.
05Update encounter forms and billing guidance to clarify that only symptomatic active OR inactive TED qualifies (expansion from prior version).
06Ensure providers and billing staff understand coverage now includes inactive TED when other criteria are met, which represents a significant policy expansion.
07Claims submitted with old Clinical Activity Score documentation or without proper active/inactive TED documentation may be delayed or denied.

Codes mentioned

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

Original notice

MA08.115b, Teprotumumab (Tepezza®)
medpolicy.ibx.com · Always check the source before changing claims.
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Related changes

See all Independence Blue Cross changes →
MA08.115b, Teprotumumab (Tepezza®)MediumEffective Jan 6, 2025 · Pharmacy08.00.41b, Teprotumumab-trbw (Tepezza®)MediumEffective Jan 6, 2025 · Pharmacy08.00.41b, Teprotumumab-trbw (Tepezza®)MediumEffective Jan 6, 2025 · Pharmacy08.00.41c, Teprotumumab-trbw (Tepezza®)LowEffective Oct 1, 2025 · PharmacyBrowse every Independence Blue Cross change in the policy list

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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