By Counterforce Health Team in Elevidys (delandistrogene moxeparvovec-rokl) —

Get Elevidys Covered by UnitedHealthcare in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Elevidys Covered by UnitedHealthcare in Michigan

UnitedHealthcare requires prior authorization for Elevidys (delandistrogene moxeparvovec-rokl) gene therapy, with mandatory step therapy through corticosteroids first. To get approved: (1) Document failed prednisone/prednisolone trials with doses and duration, (2) Submit genetic DMD confirmation and anti-AAVrh74 antibody testing showing titer ≤1:400, (3) File through the UnitedHealthcare Provider Portal with neuromuscular specialist attestation. Standard review takes 15 business days; expedited review available in 72 hours for urgent cases. If denied, Michigan patients have 127 days to file external review with the Department of Insurance and Financial Services (DIFS).

Table of Contents

  1. UnitedHealthcare Plan Types and Elevidys Coverage
  2. Formulary Status and Tier Placement
  3. Prior Authorization Requirements
  4. Step Therapy and Medical Necessity
  5. Specialty Pharmacy Network
  6. Cost-Share Considerations
  7. Submission Process
  8. Common Approval Patterns
  9. Appeals Process in Michigan
  10. Frequently Asked Questions

UnitedHealthcare Plan Types and Elevidys Coverage

UnitedHealthcare offers several plan types in Michigan, each with different implications for Elevidys coverage:

  • Commercial/Employer Plans: Require prior authorization through OptumRx specialty pharmacy network
  • Medicare Advantage: Subject to CMS oversight with 9.1% denial rate (above industry average) but 85.2% appeal success rate
  • Medicaid (UnitedHealthcare Community Plan): Coverage through Michigan's Healthy Michigan program with state-specific appeal rights
  • Marketplace/ACA Plans: Higher denial rates (~33% in-network claims) but robust appeal protections
Note: All UnitedHealthcare plans require Elevidys to be administered at designated centers of excellence, which may limit your choice of treatment facilities.

Formulary Status and Tier Placement

Elevidys is typically placed on Tier 4 (Specialty) or Tier 5 (Non-Preferred Specialty) across UnitedHealthcare formularies. This placement means:

  • Higher cost-sharing (often 25-40% coinsurance)
  • Mandatory prior authorization
  • Dispensing through specialty pharmacy only
  • Quantity limits (one lifetime dose)

The drug is not available as a preferred alternative due to its unique mechanism as the only FDA-approved gene therapy for DMD.

Prior Authorization Requirements

UnitedHealthcare requires comprehensive documentation for Elevidys prior authorization:

Clinical Documentation Required

  • DMD genetic confirmation: Complete gene mutation analysis showing pathogenic mutation between exons 18-58
  • Anti-AAVrh74 antibody testing: Serum titer must be ≤1:400 confirmed by ELISA
  • Age verification: Patient must be 4+ years old (FDA label requirement)
  • Cardiac assessment: Left ventricle ejection fraction ≥40%
  • Hepatic function: Baseline liver function tests with no preexisting impairment
  • Functional status: Current motor function assessments and disease progression notes

Provider Documentation

  • Neuromuscular specialist attestation letter
  • Treatment rationale and monitoring plan
  • Risk-benefit analysis specific to patient
  • Confirmation of center of excellence administration

Step Therapy and Medical Necessity

UnitedHealthcare mandates step therapy with corticosteroids before approving Elevidys, unless documented medical contraindications exist.

Required Prior Therapies

Medication Typical Dose Duration Documentation Needed
Prednisone 0.75 mg/kg/day 3-6 months minimum Trial record, failure evidence
Prednisolone 0.75 mg/kg/day 3-6 months minimum Inadequate response documentation

Step Therapy Exemptions

  • Medical contraindications: Documented allergies or severe adverse reactions
  • Previous failure: Clear evidence of loss of ambulation or worsening motor function
  • Urgent medical need: Rapid disease progression requiring immediate intervention
Clinician Corner: Medical necessity letters should specifically reference UnitedHealthcare's InterQual criteria, which have been used since May 2021 for utilization management decisions.

Specialty Pharmacy Network

Elevidys must be dispensed through UnitedHealthcare's designated specialty pharmacy partners:

  • Accredo Health Group: 877-222-7336
  • Optum Frontier Therapies: 855-768-9727

Contact OptumRx at 888-397-8129 to verify which specialty pharmacy is active for your specific plan and to coordinate the complex logistics of gene therapy delivery.

Cost-Share Considerations

With Elevidys' ~$3.2 million list price, understanding your cost-sharing structure is crucial:

  • Specialty tier coinsurance: Often 25-40% of drug cost
  • Out-of-pocket maximums: May provide significant protection
  • Manufacturer support: Sarepta Therapeutics offers patient assistance programs
  • Foundation grants: Multiple rare disease foundations provide financial assistance
Important: This is educational information only. Consult your plan documents and benefits administrator for specific cost-sharing details.

Submission Process

For Michigan UnitedHealthcare Members

Primary method: UnitedHealthcare Provider Portal

  • Sign in with One Healthcare ID
  • Select "Prior Authorization and Notification" tab
  • Upload all required documentation

Alternative methods:

  • Phone: 800-903-5253
  • Fax: 855-225-9847

Timeline Expectations

  • Standard review: 15 business days
  • Expedited review: 72 hours (with urgent medical justification)
  • Appeals deadline: 65 days for Medicare Advantage, 180 days for commercial plans

Common Approval Patterns

Successful Elevidys prior authorizations typically include:

  1. Complete genetic workup with specific DMD mutation identified
  2. Clear step therapy documentation showing corticosteroid trials and outcomes
  3. Specialist endorsement from recognized neuromuscular center
  4. Safety assessments confirming eligibility criteria are met
  5. Monitoring plan detailing post-infusion care and follow-up

When navigating complex prior authorizations like Elevidys, many families and clinicians find value in specialized support. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Appeals Process in Michigan

Internal Appeals with UnitedHealthcare

  1. Level 1 Internal Appeal: Submit within 65 days (Medicare Advantage) or 180 days (commercial)
  2. Level 2 Internal Appeal: If Level 1 is denied (not always required)
  3. Expedited appeals: Available for urgent cases with physician attestation

External Review through Michigan DIFS

After exhausting internal appeals, Michigan patients have 127 days to file for external review with the Department of Insurance and Financial Services (DIFS).

How to file:

Timeline:

  • Standard external review: 60 days maximum
  • Expedited external review: 72 hours (requires physician letter stating delay would harm patient)
Michigan Advantage: DIFS decisions are binding on insurers, and Michigan's 127-day deadline gives patients more time than the federal 120-day standard.

From Our Advocates

We've seen families successfully overturn Elevidys denials by strengthening their step therapy documentation. In one composite case, adding detailed dosing records and functional decline measurements to the appeal helped demonstrate that standard treatments had truly been exhausted, leading to approval on internal appeal. Every case is different, but thorough documentation often makes the difference.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Elevidys in Michigan? Standard review takes 15 business days, but expedited review is available within 72 hours if your doctor can document urgent medical need.

What if Elevidys is non-formulary on my plan? Even non-formulary drugs can be covered through the prior authorization process with strong medical necessity documentation and step therapy compliance.

Can I request an expedited appeal if UnitedHealthcare denies coverage? Yes, both internal and external appeals in Michigan offer expedited options when delays would jeopardize your health, as documented by your physician.

Does step therapy apply if I tried corticosteroids outside Michigan? Step therapy requirements are based on your medical history, not geography. Documentation of prior trials from any location should satisfy UnitedHealthcare's requirements.

What centers of excellence in Michigan can administer Elevidys? Contact UnitedHealthcare directly at 800-903-5253 to verify which Michigan facilities are designated for Elevidys administration, as this varies by plan type.

How much will Elevidys cost me out-of-pocket? Cost-sharing varies significantly by plan type and benefit design. Review your Summary of Benefits and Coverage or contact member services for specific estimates.

What happens if my appeal is denied? After exhausting UnitedHealthcare's internal appeals, you can file for external review with Michigan DIFS within 127 days. DIFS decisions are binding on the insurer.

Can Counterforce Health help with my Elevidys appeal? Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters and plan policies to identify the specific evidence needed for approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by individual plan and circumstances. Always consult your healthcare provider and insurance plan documents for decisions about your specific situation. For assistance with insurance appeals and coverage issues in Michigan, contact the Department of Insurance and Financial Services at 877-999-6442.

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