Tepezza (teprotumumab-trbw)
Billing
Code: J3241
Description: Inj. teprotumumab-trbw 10 mg
Unit: 10 mg
Payment: $327.998
Pay quarter: Q4 2023
Dosage and Frequency
Thyroid Eye Disease
Induction:
• 10mg/kg IV
Maintenance:
• 20mg/kg IV every 3 weeks for 7 doses
Induction:
• 10mg/kg IV
Maintenance:
• 20mg/kg IV every 3 weeks for 7 doses
Calculate drug reimbursement
Total Reimbursement:
$49,199.70(ASP: $46,414.81, Margin: $2,784.89)
Code:
J3241# Units to bill:
150Prior Authorization
Prior auth criteria for Tepezza may include but is not limited to:
1. The patient must have a confirmed diagnosis of Thyroid Eye Disease (TED) with active and progressive disease as evidenced by clinical evaluation, laboratory testing, and/or imaging.
2. The patient must be 18 years of age or older.
3. The patient must not have received prior treatment with teprotumumab.
4. The patient must not have received any other systemic therapies for TED within 3 months prior to initiation of teprotumumab therapy.
5. The patient must not have any active infections or other serious medical conditions that would preclude safe administration of teprotumumab.
6. The patient must have a creatinine clearance greater than or equal to 60 mL/min.
7. The patient must not have any known or suspected hypersensitivity to teprotumumab.
Insurance prior auth guidelines:
Billable NDCs
75987-0130-15
Tepezza (HORIZON)
500 MG
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