Payer PolicyActive
Teprotumumab-trbw (Tepezza)
EVICORE-MEDICAL_DRUG-9748A32D
EviCore by Evernorth
Effective: June 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered only for the FDA‑approved treatment of thyroid eye disease in adults ≥18 with active, at least moderate severity disease (off‑label/non‑FDA uses are excluded). Approval requires prescription by or consultation with an ophthalmologist, endocrinologist, or physician specializing in thyroid eye disease, documentation of diagnosis/severity/age, adherence to the dosing schedule (10 mg/kg IV initial, then 20 mg/kg IV every 3 weeks for 7 additional infusions), and is granted for 6 months.
Coverage Criteria Preview
Key requirements from the full policy
"Tepezza is indicated for the treatment of thyroid eye disease."
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