Does J3241 require prior authorization?

Yes, J3241 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J3241?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J3241`, Injection, teprotumumab-trbw, 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation defines Tepezza as an IGF-1 receptor inhibitor indicated for Thyroid Eye Disease.

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Indication: Active moderate to severe thyroid eye disease defined by lid retraction ≥ 2 mm or proptosis ≥ 3 mm or severe soft tissue involvement, in conjunction with Graves' disease, for Tepezza coverage.
Indication for Teprotumumab-trbw (Tepezza) coverage: patient aged ≥18, diagnosed with TED related to Graves' Disease, CAS ≥4, active non-sight threatening TED with functional impact, onset within 9 months, inadequate response or intolerance to high-dose IV glucocorticoids, prescribed by/with ophthalmology/endocrinology/oculoplastic surgery/neuro-ophthalmology, baseline weight provided, and must be used as single agent therapy, with euthyroid status and no unresponsive corneal decompensation or p [...]
Indication: Tepezza is indicated for patients with Thyroid Eye Disease (TED) who have active moderate-to-severe disease, defined by CAS ≥ 4 or other specified signs, or after inadequate response or contraindication to high-dose IV glucocorticoids; condition may also be considered in inactive disease with lid retraction ≥ 2 mm and mild/early optic neuropathy, in the context of autoimmune thyroid disease.

20 Active Policies

ARKBLUE-TEPROTUMUMAB-TRBW-E-G-TEPEZZA-6A1BD250AA, Teprotumumab-trbw (e.g., Tepezza)

FLORIDA_BLUE-FLBLUE-TEPROTUMUMAB-TRBW-TEPEZZATM-751F9CEB99, Teprotumumab-trbw (Tepezza)

BCIDAHO-05-01-660-E6CD67D69E, Tepezza (teprotumumab-trbw). MP 5.01.660 Tepezza CODES The following codes and coding guidance are provided for general reference purposes only and may not be all-inclusive. The inclusion of a

BCBSLA-00708-9AFC76E498, 00708 teprotumumab-trbw (Tepezza)

BCBSM-2120764-916E8BC7FB, TEPEZZA (TEPROTUMUMAB-TRBW)

BCBSMS-S-5-01-571-86CB948E7E, State and School Employees' Health Insurance Plan - Tepezza (teprotumumab-trbw)

BCBSMS-L-5-01-571-E51795D06F, Tepezza (teprotumumab-trbw)

HEALTHPARTNERS-CC-ENTRY-231638, Teprotumumab-trbw (Tepezza) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-ENTRY-226990, Teprotumumab-trbw (Tepezza)

MULTI

POINT32HEALTH-MDMNG-14066, Tepezza (teprotumumab-trbw)

MULTI

POINT32HEALTH-MDMNG-14076, Tepezza (teprotumumab-trbw)

MULTI

BCBSND-TEPROTUMUMAB-TRBW-TEPEZZA-6B7A917FCF, Teprotumumab Trbw Tepezza

BCBSNE-X-158-DF046EB1A8, TEPEZZA (PREAUTHORIZATION REQUIRED)

BCBSNJ-DRUGS-201-06E0D41640, Teprotumumab-trbw (Tepezza)

MODA-TEPEZZA-22DD2CB901, Tepezza (teprotumumab-trbw)

HEALTHNET_OR-HNOR-TEPROTUMUMAB-TEPEZZA-CP-PHAR-465-2F64E85B22, Teprotumumab (Tepezza); CP.PHAR.465

HIGHMARK_WHOLECARE-HMWC-MEDICAID-MEDICATIO-H1BF8I5VBKGUUB6D1NI00A-4F1A04CD9C, Tepezza

IBX-MEDICARE-ADVANTAGE-MA08-115C-2393AC5140, Teprotumumab (Tepezza)

IBX-COMMERCIAL-08-00-41C-7480D3EC3A, Teprotumumab-trbw (Tepezza)

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

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J3241, Injection, teprotumumab-trbw, 10 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation defines Tepezza as an IGF-1 receptor inhibitor indicated for Thyroid Eye Disease.

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Indication: Active moderate to severe thyroid eye disease defined by lid retraction ≥ 2 mm or proptosis ≥ 3 mm or severe soft tissue involvement, in conjunction with Graves' disease, for Tepezza coverage.
Indication for Teprotumumab-trbw (Tepezza) coverage: patient aged ≥18, diagnosed with TED related to Graves' Disease, CAS ≥4, active non-sight threatening TED with functional impact, onset within 9 months, inadequate response or intolerance to high-dose IV glucocorticoids, prescribed by/with ophthalmology/endocrinology/oculoplastic surgery/neuro-ophthalmology, baseline weight provided, and must be used as single agent therapy, with euthyroid status and no unresponsive corneal decompensation or p [...]
Indication: Tepezza is indicated for patients with Thyroid Eye Disease (TED) who have active moderate-to-severe disease, defined by CAS ≥ 4 or other specified signs, or after inadequate response or contraindication to high-dose IV glucocorticoids; condition may also be considered in inactive disease with lid retraction ≥ 2 mm and mild/early optic neuropathy, in the context of autoimmune thyroid disease.

20 Active Policies

ARKBLUE-TEPROTUMUMAB-TRBW-E-G-TEPEZZA-6A1BD250AA, Teprotumumab-trbw (e.g., Tepezza)

FLORIDA_BLUE-FLBLUE-TEPROTUMUMAB-TRBW-TEPEZZATM-751F9CEB99, Teprotumumab-trbw (Tepezza)

BCBSLA-00708-9AFC76E498, 00708 teprotumumab-trbw (Tepezza)

BCBSM-2120764-916E8BC7FB, TEPEZZA (TEPROTUMUMAB-TRBW)

BCBSMS-S-5-01-571-86CB948E7E, State and School Employees' Health Insurance Plan - Tepezza (teprotumumab-trbw)

BCBSMS-L-5-01-571-E51795D06F, Tepezza (teprotumumab-trbw)

HEALTHPARTNERS-CC-ENTRY-231638, Teprotumumab-trbw (Tepezza) – Minnesota Health Care Programs

MULTI

HEALTHPARTNERS-CC-ENTRY-226990, Teprotumumab-trbw (Tepezza)

MULTI

POINT32HEALTH-MDMNG-14066, Tepezza (teprotumumab-trbw)

MULTI

POINT32HEALTH-MDMNG-14076, Tepezza (teprotumumab-trbw)

MULTI

BCBSND-TEPROTUMUMAB-TRBW-TEPEZZA-6B7A917FCF, Teprotumumab Trbw Tepezza

BCBSNE-X-158-DF046EB1A8, TEPEZZA (PREAUTHORIZATION REQUIRED)

BCBSNJ-DRUGS-201-06E0D41640, Teprotumumab-trbw (Tepezza)

MODA-TEPEZZA-22DD2CB901, Tepezza (teprotumumab-trbw)

HEALTHNET_OR-HNOR-TEPROTUMUMAB-TEPEZZA-CP-PHAR-465-2F64E85B22, Teprotumumab (Tepezza); CP.PHAR.465

HIGHMARK_WHOLECARE-HMWC-MEDICAID-MEDICATIO-H1BF8I5VBKGUUB6D1NI00A-4F1A04CD9C, Tepezza

IBX-MEDICARE-ADVANTAGE-MA08-115C-2393AC5140, Teprotumumab (Tepezza)

IBX-COMMERCIAL-08-00-41C-7480D3EC3A, Teprotumumab-trbw (Tepezza)

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

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`J3241`, Injection, teprotumumab-trbw, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3241`, Injection, teprotumumab-trbw, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3241, Injection, teprotumumab-trbw, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3241, Injection, teprotumumab-trbw, 10 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3241`, Injection, teprotumumab-trbw, 10 mg

`J3241`, Injection, teprotumumab-trbw, 10 mg