Anthem (Elevance Health) Tepezza Prior Authorization: Optimizing Workflows

Tepezza: A High-Volume Prior Authorization Target

Tepezza (teprotumumab-trbw) is an infusion medication indicated for the treatment of Thyroid Eye Disease (TED). As a high-cost specialty biologic, Tepezza is consistently subject to prior authorization (PA) requirements across commercial, Medicare Advantage, and Medicaid managed care plans offered by Anthem-licensed entities, necessitating robust submission strategies.

Navigating Anthem's Prior Authorization Submission Channels

• **Medical Benefit Submissions:** For Tepezza, typically covered under the medical benefit, Anthem-licensed plans primarily utilize Availity Essentials for PA initiation, documentation upload, and status checks. Klivira supports direct integration with Availity and facilitates X12 278 transactions via clearinghouses for medical benefit PA.
• **Specialty Drug Programs:** Specialty injectables and infusions like Tepezza are subject to Anthem's site-of-care and clinical-indication policies. While most route through Availity, some may involve Carelon for review depending on the specific plan and therapeutic category.
• **Pharmacy Benefit Considerations:** While Tepezza is an infusion, it's essential to recognize that CarelonRx (formerly IngenioRx) serves as Anthem's in-house PBM. For pharmacy-benefit-managed specialty drugs, submissions route through CarelonRx's provider system or integrated ePA partners like CoverMyMeds and Surescripts.

Accessing Anthem's Tepezza Utilization Management Criteria

Anthem-licensed plans publish their medical policies and clinical utilization management guidelines via provider sites accessible through Availity. For Tepezza, clinicians must consult the specific state-licensed Anthem plan's medical policy, which outlines medical necessity criteria, step therapy requirements, and appropriate indications. These policies often indicate whether criteria are Anthem-developed, MCG-based, or NCCN-compendium-based.

Electronic PA and Turnaround Expectations for Tepezza with Anthem

Elevance Health's Anthem operating companies participate in Da Vinci Project initiatives, indicating a strategic direction towards advanced electronic PA (ePA) capabilities. For pharmacy-benefit drugs, CarelonRx leverages ePA partners like CoverMyMeds and Surescripts. For medical benefit Tepezza PA, turnaround times vary by plan type: commercial plans adhere to state-specific regulations, while Medicare Advantage and Medicaid managed care plans are subject to the CMS-0057-F rule, mandating 72-hour standard and 24-hour expedited decision timeframes.

Addressing Tepezza Denials and Appeals with Anthem

• **Typical Denial Reasons:** Denials for Tepezza PA with Anthem often stem from insufficient documentation of medical necessity, failure to meet step therapy requirements, or non-adherence to site-of-care policies. Klivira's intelligent platform helps identify potential gaps before submission.
• **Appeal Process:** When a Tepezza PA is denied, the appeal pathway typically follows the Anthem operating company's documented appeals process, accessible via the provider manual. Peer-to-peer reviews are available as part of this process, offering an opportunity for clinical discussion.
• **Documentation Best Practices:** Comprehensive clinical notes, relevant diagnostic test results, and clear justification for medical necessity are paramount. Ensuring all policy criteria are addressed in the submission package can significantly improve approval rates.