By Counterforce Health Team in Elzonris (tagraxofusp-erzs) —

Getting Elzonris (Tagraxofusp-erzs) Covered by UnitedHealthcare in Washington: Complete PA Guide

Answer Box: Your Fastest Path to Coverage

UnitedHealthcare requires prior authorization for Elzonris (tagraxofusp-erzs) and places it on specialty tier. To get approved in Washington: 1) Gather pathology confirming CD123+ BPDCN, recent labs, and clinical notes, 2) Submit PA through the UnitedHealthcare Provider Portal with complete documentation, 3) If denied, you have 180 days to appeal internally, then can request external review through Washington's Independent Review Organization (IRO) process. Start renewals 30-60 days before expiration to avoid gaps.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Process
  5. Cost-Share Basics
  6. Submission Process
  7. Common Approval Patterns
  8. Appeals Process in Washington
  9. Common Denial Reasons & Fixes
  10. Patient Support Programs
  11. FAQ

Plan Types & Coverage Implications

UnitedHealthcare offers multiple plan types in Washington, each with different coverage rules for specialty medications like Elzonris:

  • Commercial Plans: Require prior authorization through OptumRx; typically cover 6-12 months per approval
  • Medicare Advantage: Subject to Medicare Part B or D coverage rules; may have additional step therapy requirements
  • Medicaid (Apple Health): Washington's Medicaid program with its own prior authorization process through the Health Care Authority
  • Marketplace Plans: ACA-compliant plans with essential health benefits; must cover FDA-approved treatments when medically necessary
Note: Self-funded employer plans follow ERISA rules rather than Washington state insurance law, though many voluntarily adopt similar appeal processes.

Formulary Status & Tier Placement

Elzonris appears on UnitedHealthcare's 2024-2025 formularies as a specialty tier medication. This means:

  • Higher cost-sharing than standard medications
  • Must be dispensed through specialty pharmacies
  • Requires prior authorization for all indications
  • Annual reauthorization typically required

The medication is covered for its FDA-approved indication: treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and pediatric patients 2 years and older.

Prior Authorization Requirements

Medical Necessity Criteria

UnitedHealthcare requires documentation of:

  • Confirmed BPDCN diagnosis with pathology report showing CD123 positivity
  • Patient age ≥ 2 years
  • Prescription by or consultation with an oncologist or hematologist
  • Performance status: ECOG score 0-2
  • Adequate organ function: Serum albumin ≥ 3.2 g/dL before each cycle
  • Cardiac clearance: No significant cardiovascular disease
  • Exclusion of acute promyelocytic leukemia (APL)

Required Documentation

Submit these documents with your PA request:

  1. Recent pathology report confirming CD123+ BPDCN
  2. Current lab results (albumin, liver function, creatinine)
  3. Clinical notes documenting diagnosis and treatment plan
  4. Cardiac function assessment
  5. Performance status evaluation

Specialty Pharmacy Process

Elzonris must be dispensed through UnitedHealthcare's specialty pharmacy network:

  1. Verify Network Pharmacy: Confirm your specialty pharmacy is in-network for 2025
  2. Enrollment: Patient enrolls with specialty pharmacy after PA approval
  3. Coordination: Pharmacy coordinates with your clinic for delivery and administration
  4. Billing: Uses J-code J9269 (tagraxofusp-erzs, 10 mcg) for billing
Tip: Start the specialty pharmacy enrollment process as soon as your PA is approved to avoid treatment delays.

Cost-Share Basics

Specialty tier medications typically have:

  • Deductible: May apply before coverage begins
  • Coinsurance: Usually 25-40% of drug cost after deductible
  • Out-of-pocket maximum: Annual limit on member costs

Note: This is educational information only. Check your specific plan documents for exact cost-sharing details.

Submission Process

Step-by-Step Submission

  1. Access Portal: Log into the UnitedHealthcare Provider Portal
  2. Verify Requirements: Check if PA is needed for your specific member
  3. Complete Form: Fill out the electronic PA request form
  4. Upload Documents: Attach all required clinical documentation
  5. Submit: Send request and note the confirmation number
  6. Track Status: Monitor decision through the portal
  7. Follow Up: Respond promptly to any requests for additional information

Timeline: Initial decisions typically within 14 days for standard requests, 72 hours for expedited requests.

Common Approval Patterns

Successful PA submissions typically include:

  • Clear BPDCN diagnosis with immunophenotyping results
  • CD123 positivity documented in pathology report
  • Recent disease assessment showing active disease requiring treatment
  • Adequate performance status and organ function
  • Monitoring plan for capillary leak syndrome
  • Inpatient administration plan for initial cycles

Clinician Corner: Medical Necessity Letter Checklist

When writing your medical necessity letter, include:

  • Patient's BPDCN diagnosis with CD123 expression
  • Prior treatment history and outcomes
  • Clinical rationale for Elzonris therapy
  • Reference to FDA labeling and NCCN guidelines
  • Dosing plan and monitoring protocol
  • Expected treatment duration and goals

Appeals Process in Washington

If your PA is denied, Washington provides robust appeal rights:

Internal Appeals (UnitedHealthcare)

  • Timeline: 180 days from denial date to file
  • Process: Submit through provider portal or by mail/fax
  • Required: Denial letter, supporting documentation, physician letter
  • Decision: Typically within 30 days (72 hours for expedited)

External Review (Washington State)

After exhausting internal appeals, you can request external review:

  • Who: Independent Review Organization (IRO) appointed by Washington's Office of the Insurance Commissioner
  • Timeline: 180 days from final internal denial to request
  • Process: Submit request to OIC or your insurer
  • Decision: Binding determination within 30 days (72 hours if expedited)
  • Contact: Washington OIC Consumer Advocacy at 1-800-562-6900
Important: External review decisions are binding on UnitedHealthcare and cannot be appealed further.

Common Denial Reasons & Fixes

Denial Reason How to Fix Required Documentation
Insufficient diagnosis documentation Submit complete pathology report CD123+ BPDCN confirmation with immunophenotyping
Missing monitoring plan Provide CLS monitoring protocol Albumin monitoring schedule, cardiac assessment
Inadequate performance status Document functional status ECOG score assessment by oncologist
Site of care concerns Justify inpatient administration CLS risk mitigation plan, hospital capabilities

Patient Support Programs

Manufacturer Support: Stemline Therapeutics offers patient assistance programs. Contact their patient support team for eligibility screening and enrollment assistance.

Copay Assistance: May be available for commercially insured patients. Check eligibility restrictions for government-funded insurance.

State Programs: Washington residents may qualify for additional assistance through the state's prescription drug assistance programs.

When dealing with insurance challenges, Counterforce Health helps patients, clinicians, and specialty pharmacies turn denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to payer policies.

FAQ

How long does UnitedHealthcare PA take in Washington? Standard requests: up to 14 days. Expedited requests (when delay could jeopardize health): 72 hours.

What if Elzonris is non-formulary on my plan? Even non-formulary medications can be covered with strong medical necessity documentation. Request a formulary exception through the PA process.

Can I request an expedited appeal? Yes, if delay in treatment could seriously jeopardize your health. Document the urgency in your appeal request.

Does step therapy apply to Elzonris? Step therapy requirements vary by plan. Check your specific formulary for "ST" notation next to Elzonris.

What happens if I miss the appeal deadline? Contact the Washington OIC immediately. In some cases, good cause exceptions may apply for late filings.

How do I find my plan's exact requirements? Log into your UnitedHealthcare member portal or call the number on your insurance card for plan-specific information.

Can my doctor request a peer-to-peer review? Yes, peer-to-peer reviews with a UnitedHealthcare medical director are available, typically within 24 hours for urgent cases.

What if my employer plan is self-funded? Self-funded plans follow federal ERISA rules rather than Washington state law, but many offer similar appeal processes voluntarily.

For complex cases requiring detailed appeal strategies, Counterforce Health specializes in transforming insurance denials into successful appeals by identifying denial patterns and crafting evidence-based responses that align with each payer's specific requirements.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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