By Counterforce Health Team in Opdivo (nivolumab) —

Do You Qualify for Opdivo (Nivolumab) Coverage by UnitedHealthcare in Texas? Decision Tree & Next Steps

Answer Box: Getting Opdivo Covered by UnitedHealthcare in Texas

Most patients qualify for Opdivo coverage if they have an FDA-approved cancer diagnosis and meet UnitedHealthcare's prior authorization criteria. The fastest path: have your oncologist submit a prior authorization through the UnitedHealthcare Provider Portal with complete staging, biomarker results (EGFR/ALK negative for lung cancer), and documentation of any required prior therapies. If denied, request a peer-to-peer review immediately—UnitedHealthcare overturns about 85% of appealed denials. First step today: Confirm your plan type (ERISA vs. state-regulated) and gather your diagnosis, staging, and prior treatment records.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible
  4. If You're Possibly Eligible
  5. If You're Not Yet Eligible
  6. If You're Denied: Appeal Path Chooser
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Texas-Specific Appeal Rights
  10. Frequently Asked Questions
  11. Sources & Further Reading

How to Use This Guide

This decision tree helps you navigate UnitedHealthcare's Opdivo coverage requirements in Texas. Work through the eligibility questions first, then follow the specific path that matches your situation.

Important: UnitedHealthcare requires prior authorization for Opdivo across most plans. The process varies slightly between commercial plans, Medicare Advantage, and Medicaid managed care.

Tip: Have your insurance card, latest pathology report, and treatment history ready before starting.

Eligibility Triage: Do You Qualify?

Work through these questions to determine your coverage likelihood:

Step 1: Diagnosis Confirmation

Do you have an FDA-approved indication for Opdivo?

✅ Yes, if you have:

  • Melanoma (unresectable/metastatic)
  • Non-small cell lung cancer (various stages and lines)
  • Renal cell carcinoma
  • Urothelial carcinoma
  • Head and neck squamous cell carcinoma
  • Esophageal, gastric, or gastroesophageal junction cancers
  • Malignant pleural mesothelioma
  • Hepatocellular carcinoma
  • Classic Hodgkin lymphoma
  • View complete FDA-approved indications

❌ Not yet, if: Your cancer type isn't FDA-approved for Opdivo

Step 2: Biomarker Requirements

For lung cancer patients: Do you have EGFR/ALK testing results?

✅ Yes, and they're negative → Continue to Step 3 ⚠️ Yes, and they're positive → Opdivo typically not first-line; discuss alternatives ❓ No testing done → Request testing before prior authorization

For other cancers: PD-L1 testing is not required for Opdivo in most approved indications.

Step 3: Prior Therapy Requirements

Has your cancer progressed on or are you intolerant to standard first-line treatments?

This varies by cancer type and stage. UnitedHealthcare often requires documentation of:

  • Prior chemotherapy regimens tried and failed
  • Contraindications to preferred alternatives
  • Disease progression with imaging or clinical evidence

If You're Likely Eligible

Document Checklist

Gather these items before your oncologist submits the prior authorization:

Clinical Documentation:

  • Pathology report confirming diagnosis
  • Staging studies (CT, PET, MRI as appropriate)
  • EGFR/ALK testing results (lung cancer)
  • Prior treatment history with dates and outcomes
  • Current performance status
  • Laboratory values (CBC, comprehensive metabolic panel)

Insurance Information:

  • UnitedHealthcare member ID
  • Group number
  • Plan type (commercial, Medicare Advantage, Medicaid)

Submission Path

  1. Oncologist submits prior authorization via UnitedHealthcare Provider Portal
  2. Timeline: Standard review takes up to 15 business days; expedited review available for urgent cases
  3. Follow up: Check status online or call the number on your insurance card
Clinician Corner: Include NCCN guideline references in your medical necessity letter. UnitedHealthcare recognizes NCCN as a standard of care for oncology decisions.

If You're Possibly Eligible

Additional Tests to Request

  • Biomarker testing if not already done
  • Staging studies to confirm extent of disease
  • Second opinion if diagnosis or staging is uncertain

Timeline to Re-apply

  • Complete missing tests within 2-4 weeks
  • Resubmit prior authorization with updated documentation
  • Consider requesting expedited review if treatment delays could affect outcomes

If You're Not Yet Eligible

Alternatives to Discuss

  • FDA-approved alternatives for your cancer type
  • Clinical trial participation
  • Off-label use with strong supporting evidence

Preparing for Exception Requests

UnitedHealthcare may approve off-label uses with compelling evidence:

  • Peer-reviewed literature supporting use
  • Recognized drug compendia (e.g., NCCN, Micromedex)
  • Expert opinion from oncology specialists

When patients face complex coverage challenges like these, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

If You're Denied: Appeal Path Chooser

Internal Appeal (First Level)

Deadline: 180 days from denial notice How to file:

  • Online: UnitedHealthcare member portal
  • Phone: Number on your insurance card
  • Mail: Address provided in denial letter

Peer-to-Peer Review

When to request: Immediately after denial Process: Your oncologist discusses the case directly with a UnitedHealthcare medical director Success rate: High for cases with strong clinical evidence

External Review (Texas)

Eligibility: Only for fully-insured plans (not ERISA self-funded) Process: Independent Review Organization through Texas Department of Insurance Timeline: 30 days for standard review, 5 days for urgent cases

Note: ERISA self-funded plans are exempt from Texas external review. Check with your employer's benefits department to confirm your plan type.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Pre-approval required UnitedHealthcare formulary PA Requirements
Step Therapy Try preferred drugs first Plan documents Provider Resources
Site of Care Infusion location restrictions Coverage policy Varies by plan
Quantity Limits Dose/frequency restrictions Formulary Plan-specific

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing biomarker testing Submit EGFR/ALK results for lung cancer
Inadequate prior therapy Document failed treatments with dates and outcomes
Off-label use Provide NCCN guidelines or peer-reviewed literature
Quantity exceeded Submit dosing rationale based on patient weight/BSA
Site of care Request exception with clinical justification

Texas-Specific Appeal Rights

Texas provides strong consumer protections for insurance denials:

Internal Appeals:

  • Must be completed before external review
  • 180-day deadline from denial notice
  • Insurer must respond within 30 days (pre-service) or 60 days (post-service)

External Review:

  • Available for fully-insured plans only
  • Conducted by Independent Review Organization (IRO)
  • Decision is binding on the insurer
  • No cost to the patient

Contact Information:

  • Texas Department of Insurance: 1-800-252-3439
  • IRO Information Line: 1-866-554-4926
  • Office of Public Insurance Counsel: 1-877-611-6742

For complex appeals requiring detailed medical evidence and payer-specific expertise, Counterforce Health helps patients and clinicians navigate the appeals process by identifying denial reasons and crafting targeted responses with appropriate clinical citations and operational details.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Texas? Standard review: up to 15 business days. Expedited review for urgent cases: typically 72 hours or less.

What if Opdivo isn't on my formulary? Request a formulary exception with clinical justification. UnitedHealthcare may cover non-formulary drugs with compelling medical necessity.

Can I request an expedited appeal? Yes, if delays in treatment could seriously jeopardize your health. This applies to both internal appeals and external reviews.

Does step therapy apply if I failed treatments outside Texas? Yes, UnitedHealthcare recognizes prior therapy failures from other states with proper documentation.

What's the difference between commercial and Medicare Advantage appeals? Medicare Advantage follows federal CMS rules with different timelines. Commercial plans follow UnitedHealthcare's standard process unless state law requires otherwise.

How much does Opdivo cost without insurance? List price is approximately $7,943 per 240-mg vial. Total treatment cost varies by dosing schedule and duration.

From Our Advocates

We've seen many Opdivo denials overturned when oncologists include specific NCCN guideline references and document why alternative treatments aren't appropriate for the patient's specific situation. The key is matching clinical evidence to the payer's own coverage criteria rather than making general medical necessity arguments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with complex appeals, contact qualified advocacy organizations or legal counsel familiar with health insurance law.

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