Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after October 1, 2020, Teprotumumab-trbw (Tepezza) (procedure code C9061) a benefit of Texas Medicaid will require prior authorization. Teprotumumab-trbw (Tepezza) is indicated for the treatment of thyroid eye disease (TED) in adults and must be prescribed by, or in consultation with, an ophthalmologist or endocrinologist.
Prior Authorization Requirements
Prior authorization requests for procedure code C9061 must be submitted with a Special Medical Prior Authorization (SMPA) Request Form.
Documentation of the client’s dosage, administration schedule, number of doses to be administered during the prior authorization period, the requested units per dose, and the dosage calculation must be submitted in Section C of the Special Medical Prior Authorization (SMPA) Request Form under the Statement of Medical Necessity.
The Special Medical Prior Authorization (SMPA) Request Form must be completed, signed, and dated by the prescribing provider. The Special Medical Prior Authorization (SMPA) Request Form will not be accepted beyond 90 days from the date of the prescribing provider’s signature.
The completed Special Medical Prior Authorization (SMPA) Request Form must be maintained by the prescribing provider in the client’s medical record and is subject to retrospective review.
The client must meet all of the following requirements for approval of Teprotumumab-trbw (Tepezza):
- The client has a diagnosis of Graves’ disease associated with active TED.
- The client has active TED with a clinical activity score (CAS) of 4 or greater.
- The client is euthyroid, or the client has either mild hypothyroidism or mild hyperthyroidism.
- The client has no history of prior surgical intervention for TED and does not plan to have surgical treatment while on Teprotumumab-trbw (Tepezza).
- The client may not exceed the course of eight total infusions per lifetime.
For more information, call the TMHP Contact Center at 800-925-9126.