Please ensure JavaScript is enabled for purposes of website accessibility Enrollment Form and Resources | TEPEZZA® (teprotumumab-trbw) for HCPs

Downloads

Helpful resources and downloadable assets to support your practice and your patients

Patient-Enrollment-Form-Icon

Patient
Enrollment Form

Download the form, complete it with your patient, including HCP and patient signatures, and submit by fax or email. Bookmark this page for next time!

DOCUSIGN-Icon

DocuSign® eSignature Patient Enrollment Form

Complete the form and send to your patient via email to sign electronically via DocuSign®.

Treatment Initiation Resources

patient-enrollment-form-checklist
Patient Enrollment Form Checklist

Important checklist detailing steps to enroll, educate, and connect TEPEZZA patients with PALs for successful treatment.

tepezza-at-your-practice
TEPEZZA At Your Practice

A guide to clinical, access, and reimbursement considerations for TEPEZZA.

soc-guide
Site of Care (SOC) Guide

Helpful information to consider when selecting a site of care for your patient’s
infusion of TEPEZZA.

Care-Team-Notification
Care Team Notification

A customizable letter used to notify co-managers and coordinate patient
monitoring when TEPEZZA is initiated.

home-infusion-faq
Home Infusion FAQs

Answers to common questions about home infusion for TEPEZZA.

Home-Infusion-Brochure
Home Infusion Brochure

Considerations for choosing home infusion for TEPEZZA.

Payor Access Resources

Clinical-Documentation-Guide
Clinical Documentation Guide

A guide to documenting TED symptomatology with a focus on capturing key clinical criteria, such as Clinical Activity Score (CAS).

Clinical-Documentation-Tearpad
Clinical Documentation Tearpad

A form that outlines the CAS that is used to evaluate the inflammatory signs and symptoms of TED.

Letter-of-Medical-Necessity-Template
Letter of Medical Necessity Template

A customizable template for a letter of medical necessity to support PA for TEPEZZA.

Payor-Appeal-Letter-Template
Payor Appeal Letter Template

A customizable appeals template for patient cases that were denied PA.

Billing and Coding Resources

Acquisition-Overview
Acquisition Overview

A guide to TEPEZZA specialty distributors, specialty pharmacies, and ordering.

Product-Fact Sheet
Product Fact Sheet

Product information, including NDC, packaging, storage, handling, and authorized distributor list.

Billing-and-Coding-Guide
Billing and Coding Guide

A guide to billing procedures, necessary codes, and reimbursement with J-code.

Coding-at-a-Glance
Coding at a Glance

A guide to necessary codes for billing and reimbursement with J-code.

Infusion Resources

Infusion-Checklist
Infusion Checklist

A step-by-step checklist for the infusion process.

Infusion-Manual
Infusion Manual

A detailed guide to preparing, administering, and infusing TEPEZZA.

Infusion-Administration-Video
Infusion Administration Video

Key steps required for reconstitution, dilution, and administration of TEPEZZA.

Patient Education Resources

Patient-Brochure
Getting Started on TEPEZZA Patient Brochure

A brochure to guide your patients through the initial steps of getting started 
on TEPEZZA.

getting-started-on-tepezza-video-thumbnail
Getting Started on TEPEZZA Video

A video to help your patients understand how to get started on TEPEZZA.

Insurance-Approval-Guide
TEPEZZA PSK Insurance Approval Guide

A brochure to guide your patients through insurance coverage and approval of 
TEPEZZA.

Infusion-Reminder-List
TEPEZZA Pre-Infusion Reminder List

A list that helps your patients prepare for TEPEZZA infusions.

Post-Infusion-Reminder-List
TEPEZZA Post-Infusion Reminder List

A list that helps your patients stay on track after each TEPEZZA infusion.

For additional resources for your practice, please visit Amgen By Your Side.

For additional resources for your patients, please visit TEPEZZA patient website.

IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS

Infusion Reactions: TEPEZZA may cause infusion reactions. Infusion reactions have been reported in approximately 4% of patients treated with TEPEZZA. Reported infusion reactions have usually been mild or moderate in severity. Signs and symptoms may include transient increases in blood pressure, feeling hot, tachycardia, dyspnea, headache, and muscular pain. Infusion reactions may occur during an infusion or within 1.5 hours after an infusion. In patients who experience an infusion reaction, consideration should be given to premedicating with an antihistamine, antipyretic, or corticosteroid and/or administering all subsequent infusions at a slower infusion rate.

Inflammatory Bowel Disease: TEPEZZA may cause an exacerbation of inflammatory bowel disease (IBD). IBD has been reported in some patients without a prior diagnosis of IBD. Monitor patients for signs and symptoms of IBD. If IBD exacerbation is suspected, discontinue use of TEPEZZA.

Hyperglycemia: Increased blood glucose or hyperglycemia may occur in patients treated with TEPEZZA. In clinical trials, 10% of patients (two-thirds of whom had preexisting diabetes or impaired glucose tolerance) experienced hyperglycemia. Hyperglycemic events should be controlled with medications for glycemic control, if necessary. Assess patients for elevated blood glucose and symptoms of hyperglycemia prior to infusion and continue to monitor while on treatment with TEPEZZA. Ensure patients with hyperglycemia or preexisting diabetes are under appropriate glycemic control before and while receiving TEPEZZA.

Hearing Impairment Including Hearing Loss: TEPEZZA may cause severe hearing impairment including hearing loss, which in some cases may be permanent. Assess patients’ hearing before, during, and after treatment with TEPEZZA and consider the benefit-risk of treatment with patients.

ADVERSE REACTIONS

The most common adverse reactions (incidence ≥5% and greater than placebo) are muscle spasm, nausea, alopecia, diarrhea, fatigue, hyperglycemia, hearing impairment, dysgeusia, headache, dry skin, ear discomfort, weight decreased, nail disorders, and menstrual disorders.

INDICATION

TEPEZZA is indicated for the treatment of Thyroid Eye Disease regardless of Thyroid Eye Disease activity or duration.

Please see Full Prescribing Information for more information.

IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS Infusion Reactions: TEPEZZA may cause infusion reactions. Infusion reactions have been reported in approximately 4% of patients treated with TEPEZZA. Reported infusion reactions have usually been mild or moderate in severity. Signs and symptoms may include transient increases in blood pressure, feeling hot, tachycardia, dyspnea, headache, and muscular pain. Infusion reactions