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

MA08.115b, Teprotumumab (Tepezza®)

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

Summary

Independence Blue Cross updated MA08.115b to MA08.115c, 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 ICD-10 diagnosis codes. The policy now includes additional criteria for patients with planned surgical ophthalmological intervention and clarifies that cosmetic use is not covered.

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What to do

by Jan 6, 2025 · 7 steps
01Billing team must update billing system and prior authorization workflows to reflect expanded coverage for both active AND inactive moderate-to-severe TED (removal of Clinical Activity Score requirement).
02Update claim submission templates and EMR encounter forms to include all new ICD-10 diagnosis codes (E05.10, E05.20, E05.30, E05.80, E05.90, H05.89 in addition to existing codes).
03Add requirement to documentation checklist: Verify patient does NOT have planned surgical ophthalmological intervention before approving.
04Add cosmetic use screening to prior authorization request forms—if request is solely for appearance improvement, deny as cosmetic/non-covered service.
05Remove any remaining references to Clinical Activity Score from clinical criteria requirements.
06Notify ophthalmology and endocrinology providers of expanded eligibility criteria.
07Claims submitted without updated coding or that fail to document absence of planned surgical intervention may be delayed or denied.

Codes mentioned

J3241E05.00E05.10E05.20E05.30E05.80E05.90H05.831H05.832H05.833H05.89

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 →
08.00.41c, Teprotumumab-trbw (Tepezza®)LowEffective Oct 1, 2025 · PharmacyMA08.115b, 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 · PharmacyBrowse every Independence Blue Cross change in the policy list

Related policy hubs

Independence Blue Cross policiesOphthalmologyEndocrinologyPharmacyCode J3241Code E05.00Code E05.10Code E05.20Code E05.30Code E05.80Code E05.90Code H05.831Code H05.832Code H05.833Code H05.89

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