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Prior Authorization Criteria for Teprotumumab-trbw (Tepezza) Updated Effective December 1, 2023

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Teprotumumab-trbw (Tepezza) is indicated for the treatment of thyroid eye disease (TED) regardless of TED activity or duration.

Effective for dates of service on or after December 1, 2023, the following prior authorization requirements will be updated as follows for the approval of teprotumumab-trbw (Tepezza):

  • The client’s diagnosis of Graves’ disease does not have to be associated with active TED.
  • The clinical activity score (CAS) of 4 or greater for a client is no longer required.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.101.1, “Prior Authorization Requirements,” for additional prior authorization requirements.

For more information, call the TMHP Contact Center at 800-925-9126.