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

Get Elevidys Covered by UnitedHealthcare in Pennsylvania: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Elevidys Covered by UnitedHealthcare in Pennsylvania

Elevidys requires prior authorization from UnitedHealthcare in Pennsylvania. Your fastest path to approval: (1) Verify your plan covers specialty gene therapies through OptumRx, (2) Have your doctor submit a complete PA request via the UnitedHealthcare Provider Portal with genetic confirmation and anti-AAV antibody results ≤1:400, and (3) Ensure treatment at an approved center of excellence. If denied, Pennsylvania's new external review process has a 50% overturn rate. Start by calling OptumRx Specialty at 888-397-8129 to verify requirements and coordinate your case.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Mandatory PA through OptumRx before coverage UnitedHealthcare PA Requirements
Genetic Confirmation Lab-confirmed DMD gene mutation Your doctor's records
Anti-AAV Antibody Test Serum titer must be ≤1:400 Pre-treatment blood work
Center of Excellence Treatment at UHC-approved facility UHC Specialty Network
Age Requirements Per FDA label (typically 4-5 years) FDA Elevidys Label
Appeal Deadline 180 days from denial letter Denial letter instructions

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan Coverage (Patient/Family)

Timeline: Same day
Action: Call the member services number on your insurance card and ask: "Does my plan cover Elevidys through OptumRx specialty pharmacy?"
Document needed: Insurance card
Next step: If covered, proceed to step 2. If not, ask about exceptions or alternative plans.

2. Coordinate with OptumRx Specialty (Doctor's Office)

Timeline: 1-2 business days
Action: Call OptumRx Specialty at 888-397-8129 to initiate case management and verify PA requirements
Documents needed: Patient demographics, diagnosis, insurance information
Portal: OptumRx Provider Resources

3. Complete Required Testing (Patient)

Timeline: 1-2 weeks
Action: Get genetic confirmation of DMD mutation and anti-AAV antibody testing
Documents needed: Lab orders from your doctor
Critical: Antibody titer must be ≤1:400 for coverage eligibility

4. Submit Prior Authorization (Doctor's Office)

Timeline: Same day submission
Action: Complete PA request through UnitedHealthcare Provider Portal
Required documents: Genetic test results, antibody results, clinical notes, treatment plan
Portal: UHC Provider Portal
Fax backup: 1-844-403-1027

5. Follow Up on Decision (Patient/Doctor)

Timeline: 15 business days for standard review
Action: Check portal status or call OptumRx at 888-397-8129
If approved: Coordinate infusion scheduling
If denied: Proceed to appeals process immediately

Forms and Submission Portals

UnitedHealthcare Provider Portal

The primary method for PA submissions requires a One Healthcare ID with multifactor authentication. Access the "Prior Authorization and Notification" tool after logging in.

Portal Access: UHCprovider.com
Setup: Each user needs individual credentials - no sharing allowed
Features: Real-time status tracking, document upload, expedited review requests

OptumRx Prior Authorization Forms

Always use the most current version - forms are updated frequently and old versions cause delays.

Current forms: OptumRx.com/forms.html
Fax number: 1-844-403-1027
Electronic PA: Available through CoverMyMeds platform

Tip: Download forms fresh each time rather than saving copies. OptumRx frequently updates requirements and won't process outdated versions.

Required Documentation Checklist

  • Completed PA request form (current version only)
  • Genetic test results confirming DMD mutation
  • Anti-AAV antibody titer results (≤1:400)
  • Clinical notes supporting medical necessity
  • Previous treatment history and failures
  • Planned center of excellence for administration
  • Insurance verification and member ID

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn
Missing genetic confirmation Submit certified lab results showing specific DMD gene mutation
Anti-AAV antibody titer too high (>1:400) Retest after waiting period or request exception with clinical justification
Treatment center not approved Transfer care to UHC-approved center of excellence or request network exception
Incomplete clinical documentation Submit comprehensive medical necessity letter with treatment history
Age outside FDA label Provide clinical evidence supporting off-label use with safety data
Missing prior therapy documentation Document previous treatments, failures, or contraindications to alternatives

Medical Necessity Letter Components

When appealing or submitting initial PA, your doctor's letter should include:

  • Specific DMD genetic mutation details
  • Patient's current functional status and decline trajectory
  • Previous treatments tried and why they failed or are contraindicated
  • Clinical rationale for gene therapy timing
  • Safety monitoring plan including hepatic function surveillance
  • References to FDA approval and clinical trial data

Appeals Process in Pennsylvania

Pennsylvania offers both internal UnitedHealthcare appeals and a new state-level external review process with strong patient success rates.

Internal Appeals (Required First Step)

Deadline: 180 days from denial letter
Method: Online through provider portal, mail, or fax
Address: UnitedHealthcare Member Grievance & Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

Urgent appeals fax: 1-866-373-1081
Standard timeline: 30 days for decision
Expedited timeline: 72 hours for urgent cases

Pennsylvania External Review Process

After completing internal appeals, Pennsylvania's Independent External Review Program offers a second chance with impressive success rates.

Success rate: 50.1% of denials overturned in 2024
Deadline: 4 months after final internal denial
Submission: Online at PA.gov external review portal
Timeline: 45 days for standard review, 72 hours for expedited
Cost: Free to consumers

Required documents:

  • Final denial letter from UnitedHealthcare
  • All internal appeal correspondence
  • Supporting medical records and research
  • Completed external review request form
Note: This process only applies to fully-insured commercial plans, not self-funded employer plans. Check with your HR department if unsure.

Specialty Pharmacy Coordination

Elevidys requires coordination through UnitedHealthcare's specialty pharmacy network, primarily OptumRx Specialty Pharmacy.

OptumRx Specialty Pharmacy Setup

Phone: 1-855-427-4682 (24/7 support)
Services: Case management, prior authorization coordination, infusion site coordination
Required: All specialty medications must go through approved specialty pharmacy

Transfer Process

  1. Doctor sends prescription to OptumRx Specialty
  2. OptumRx coordinates with approved infusion center
  3. Patient receives pre-infusion counseling and scheduling
  4. Insurance benefits verified and copay assistance applied
  5. Drug shipped directly to infusion center

Important: Retail pharmacies cannot dispense Elevidys. Attempting to fill elsewhere will result in claim rejection.

Support Contacts and Scripts

For Patients Calling UnitedHealthcare

"Hi, I'm calling about prior authorization for Elevidys, generic name delandistrogene moxeparvovec-rokl, for my [son/daughter] with Duchenne muscular dystrophy. Can you tell me the current status of our request and what additional information might be needed?"

Member services: Number on your insurance card
OptumRx Specialty: 888-397-8129
PA status line: 1-800-310-6826

For Providers Requesting Peer-to-Peer Review

"I'm requesting a peer-to-peer review for Elevidys prior authorization denial. This is for a DMD patient who meets all FDA criteria with confirmed genetic mutation and appropriate antibody titers. I have clinical evidence supporting medical necessity."

Provider services: 1-877-842-3210
Best times to call: Mid-morning, avoid Mondays and Fridays

Pennsylvania External Review Process

Pennsylvania's new external review system, launched in January 2024, provides significant leverage for overturning UnitedHealthcare denials.

When to Use External Review

  • After completing all internal UnitedHealthcare appeals
  • Within 4 months of final denial letter
  • For fully-insured commercial plans (not self-funded employer plans)
  • When you have strong clinical evidence supporting medical necessity

How to Submit

  1. Visit the PA Insurance Department portal
  2. Complete the online external review request
  3. Upload all denial letters and supporting documentation
  4. Submit within 4-month deadline

What Happens Next

  • PID reviews eligibility within 5 business days
  • Independent Review Organization (IRO) assigned within 1 business day
  • You have 15 days to submit additional supporting information
  • IRO makes binding decision within 45 days (72 hours if expedited)
  • If overturned, UnitedHealthcare must provide coverage immediately

Consumer assistance: Pennsylvania Insurance Department at (877) 881-6388

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Elevidys in Pennsylvania?
Standard review takes up to 15 business days. Expedited review for urgent cases is completed within 72 hours. Status can be checked through the provider portal or by calling OptumRx at 888-397-8129.

What if Elevidys is not on my UnitedHealthcare formulary?
Gene therapies like Elevidys typically require individual case review regardless of formulary status. The PA process evaluates medical necessity even for non-formulary drugs. Your doctor can request a formulary exception with supporting clinical documentation.

Can I request an expedited appeal if my child's condition is worsening?
Yes. If there's immediate health risk or significant functional decline, request expedited review. Mark all correspondence as "URGENT" and fax to 1-866-373-1081. Include documentation of clinical urgency from your doctor.

Does step therapy apply to Elevidys in Pennsylvania?
UnitedHealthcare may require documentation of previous DMD treatments and their outcomes, but true step therapy (trying specific drugs first) is less common for gene therapy. Your doctor should document why immediate gene therapy is appropriate.

What if my employer health plan is self-funded?
Self-funded plans aren't subject to Pennsylvania's external review process. However, they often have their own appeals procedures. Check your Summary Plan Description or contact HR for specific appeal rights and processes.

How much will Elevidys cost with UnitedHealthcare coverage?
With prior authorization approval, your cost depends on your plan's specialty drug tier and out-of-pocket maximum. The manufacturer offers patient assistance programs. Contact OptumRx Specialty at 888-397-8129 for benefit verification and copay assistance information.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address each payer's specific requirements. For complex cases like Elevidys coverage, we identify the exact clinical documentation and regulatory citations needed to meet UnitedHealthcare's criteria and maximize approval chances.

When facing a UnitedHealthcare denial for Elevidys, having the right clinical evidence and procedural approach makes the difference between coverage and continued appeals. Counterforce Health specializes in crafting appeals that speak directly to payer policies while meeting Pennsylvania's regulatory requirements for external review.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not replace professional medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance representative for personalized guidance. For additional help with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department Consumer Services at (877) 881-6388.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.