By Counterforce Health Team in Tagrisso (osimertinib) —

Do You Qualify for Tagrisso Coverage by UnitedHealthcare in Illinois? Decision Tree & Next Steps

Answer Box: Quick Path to Tagrisso Coverage in Illinois

Yes, you likely qualify if you have NSCLC with EGFR mutations (exon 19 deletion, L858R, T790M, S768I, L861Q, or G719X). UnitedHealthcare requires prior authorization through OptumRx with mutation test results and treatment history. First step today: Have your oncologist submit a PA request via the UnitedHealthcare Provider Portal with complete EGFR documentation. If denied, you have 180 days to appeal internally, then can request Illinois external review within 4 months. Processing typically takes 15 business days (72 hours if expedited).

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Options
  6. If Denied: Illinois Appeal Path
  7. Coverage at a Glance
  8. Common Denial Reasons & Fixes
  9. FAQ
  10. Resources & Contact Information

How to Use This Decision Tree

This guide helps Illinois patients and their oncologists navigate UnitedHealthcare's prior authorization process for Tagrisso (osimertinib). Start with the eligibility triage below, then follow the path that matches your situation. Each section includes specific documents, submission methods, and timelines based on UnitedHealthcare's current policy and Illinois insurance law.

Note: This information applies to UnitedHealthcare commercial plans and Medicare Advantage in Illinois. Self-insured employer plans may have different requirements.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible if you have:

  • Confirmed NSCLC diagnosis with pathology report
  • Positive EGFR mutation from FDA-approved test showing:
    • Exon 19 deletions, OR
    • Exon 21 L858R substitution, OR
    • T790M resistance mutation (after prior EGFR TKI), OR
    • S768I, L861Q, or G719X mutations
  • Appropriate disease stage: Metastatic, locally advanced, or adjuvant (stage IB-IIIB after complete resection)
  • Correct line of therapy: First-line for del19/L858R; post-progression for T790M

⚠️ Possibly Eligible if you have:

  • NSCLC diagnosis but pending EGFR test results
  • EGFR mutation but unclear treatment history documentation
  • Borderline disease stage or complex clinical scenario
  • Insurance coverage questions (new plan, recent changes)

❌ Not Yet Eligible if you have:

  • EGFR-negative or EGFR-unknown NSCLC
  • Early-stage disease not meeting adjuvant criteria
  • No prior EGFR TKI failure for T790M-positive tumors
  • Active coverage issues with UnitedHealthcare

If "Likely Eligible": Document Checklist

Your oncologist needs these documents for the prior authorization submission:

Required Clinical Documentation

  • Pathology report confirming NSCLC with stage and histology
  • EGFR mutation test results from FDA-approved laboratory
  • Treatment plan with dosing rationale and duration
  • Prior therapy history (especially for T790M cases)
  • ICD-10 diagnosis codes (verify with the source linked below)

Submission Process

  1. Submit via: UnitedHealthcare Provider Portal
  2. Processing time: 15 business days standard, 72 hours expedited
  3. Specialty pharmacy: Must use Optum Specialty Pharmacy once approved
  4. Authorization period: 12 months with reauthorization required
Clinician Tip: Request expedited review if disease progression is rapid or patient has aggressive NSCLC. Include clinical urgency statement in the PA request.

If "Possibly Eligible": Tests to Request

Missing EGFR Results

  • Request comprehensive EGFR mutation panel including:
    • Exon 19 deletions and exon 21 L858R (most common)
    • T790M resistance mutation
    • Less common mutations (S768I, L861Q, G719X)
  • Use FDA-approved testing method (tissue or liquid biopsy)
  • Timeline: Results typically available in 5-7 business days

Unclear Treatment History

  • Gather complete prior therapy records including:
    • Previous EGFR TKIs tried (erlotinib, gefitinib, afatinib)
    • Response duration and reason for discontinuation
    • Imaging showing progression or intolerance documentation
  • Re-apply once documentation is complete

If "Not Yet": Alternative Options

EGFR-Negative Patients

  • Discuss alternative targeted therapies:
    • ALK inhibitors (if ALK-positive)
    • ROS1 inhibitors (if ROS1-positive)
    • PD-L1 inhibitors based on expression level
  • Consider clinical trials for novel targeted agents

Coverage Exception Requests

  • Submit medical necessity letter citing:
    • NCCN Guidelines for NSCLC treatment
    • Published literature supporting off-label use
    • Contraindications to standard alternatives
  • Include peer-reviewed studies and specialty society recommendations

If Denied: Illinois Appeal Path

Illinois patients have strong appeal rights under the Health Carrier External Review Act.

Step 1: Internal Appeal (Required First)

  • Timeline: File within 180 days of denial
  • Method: UnitedHealthcare member portal or written request
  • Decision time: 15 business days (24 hours if expedited)
  • Success rate: ~85% of appeals are overturned with proper documentation

Step 2: Peer-to-Peer Review

  • Request: Your oncologist can request direct discussion with UnitedHealthcare medical director
  • Timing: Often resolves issues faster than formal appeal
  • Preparation: Have clinical literature and guidelines ready

Step 3: Illinois External Review

  • Eligibility: After completing internal appeal process
  • Timeline: Must request within 4 months of final denial (shorter than many states)
  • Process: Independent Review Organization (IRO) with oncology expertise
  • Decision time: 5 business days after IRO receives records
  • Cost: Free to consumers
  • Binding: If IRO approves, UnitedHealthcare must cover treatment
Illinois-Specific: The 4-month deadline is stricter than the typical federal requirement. Don't delay if your internal appeal is denied.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all plans UHC Policy
Formulary Tier Tier 3 specialty OptumRx formulary
EGFR Testing FDA-approved methods only UHC medical policy
Specialty Pharmacy Optum Specialty required UHC network requirements
Authorization Period 12 months initial/renewal UHC policy document
Appeal Deadline 180 days internal UHC member agreement
External Review Deadline 4 months in Illinois Illinois DOI

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
Missing EGFR mutation Submit FDA-approved test results Laboratory report with specific mutations
Wrong line of therapy Clarify treatment sequence Prior therapy timeline and progression notes
Insufficient medical necessity Provide clinical rationale NCCN guidelines citation, treatment goals
Missing prior authorization Resubmit complete PA request All required clinical documentation
Quantity limits exceeded Request exception with rationale Dosing justification from oncologist

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Illinois? Standard processing is 15 business days. Expedited requests (for urgent cases) are processed within 72 hours. Your oncologist can request expedited review if delay would harm your health.

What if Tagrisso is not on my formulary? Tagrisso is typically on Tier 3 of UnitedHealthcare formularies. If it's not covered, your doctor can request a formulary exception with medical necessity documentation and evidence that preferred alternatives are inappropriate.

Can I get expedited appeal in Illinois? Yes, if delay would seriously jeopardize your health. Both internal appeals and external reviews can be expedited. The Illinois external review process provides decisions within 24-72 hours for urgent cases.

Does step therapy apply to Tagrisso? UnitedHealthcare's current policy doesn't require step therapy for first-line EGFR-mutated NSCLC. However, for T790M resistance mutations, you must have tried and failed a prior EGFR TKI.

What if I have Medicare Advantage through UnitedHealthcare? The same prior authorization requirements apply. Medicare Advantage has additional federal appeal rights, and UnitedHealthcare's Medicare plans have a 9.1% denial rate with 85% appeal success rate.

Where can I get help with my appeal in Illinois? Contact the Illinois Department of Insurance at 877-527-9431 or the Illinois Attorney General's Health Care Bureau at 1-877-305-5145.

From our advocates: We've seen many Tagrisso denials overturned when oncologists include specific EGFR mutation details and cite NCCN Guidelines in their medical necessity letters. The key is addressing every point in the denial letter with clinical evidence. Most successful appeals also include a brief summary of why alternative treatments aren't appropriate for the patient's specific mutation profile.

Resources & Contact Information

For patients navigating complex insurance denials and appeals, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals aligned to UnitedHealthcare's own rules, pulling the right clinical evidence and citations to support your case.

Official Resources

Emergency Contacts

  • UnitedHealthcare Member Services: Number on your insurance card
  • Illinois DOI Consumer Hotline: 877-527-9431
  • Illinois AG Health Care Bureau: 1-877-305-5145

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for decisions about your specific situation. Insurance policies and state regulations may change; verify current requirements with official sources.

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