By Counterforce Health Team in Enbrel (etanercept) —

Getting Enbrel (Etanercept) Covered by UnitedHealthcare in New York: A Real Patient Journey From Denial to Approval

Answer Box: Getting Enbrel Covered by UnitedHealthcare in New York

Fastest path to approval: Submit prior authorization through UnitedHealthcare's provider portal with specialist prescription, documented DMARD failure, negative TB screening, and medical necessity letter. If denied, file internal appeal within 180 days, then external review through NY Department of Financial Services within 4 months. Start today: Contact your rheumatologist to initiate the PA process and gather required documentation.

Table of Contents

  1. Patient Profile: Meet Maria
  2. Pre-Authorization Preparation
  3. Submission Process
  4. Initial Outcome: The Denial
  5. The Appeal Strategy
  6. Resolution: Approval at Last
  7. What We'd Do Differently
  8. Templates & Checklists
  9. FAQ

Patient Profile: Meet Maria

Maria, a 42-year-old teacher from Rochester, New York, was diagnosed with moderate to severe rheumatoid arthritis in 2022. After 18 months of progressively worsening joint pain and morning stiffness, her rheumatologist recommended Enbrel (etanercept) when methotrexate and sulfasalazine failed to control her symptoms.

Her insurance: UnitedHealthcare PPO through her school district
Her goal: Get Enbrel covered to return to work full-time
The challenge: UnitedHealthcare's step therapy requirements and prior authorization process

Like many New Yorkers with autoimmune conditions, Maria faced the reality that specialty biologics require extensive documentation and often multiple appeals before approval.

Pre-Authorization Preparation

Maria's rheumatologist, Dr. Chen, knew that thorough preparation was crucial for UnitedHealthcare approval. Here's what they gathered:

Required Documentation Checklist

Document Purpose Source
TB Screening (negative within 12 months) Safety requirement for TNF inhibitors FDA prescribing information
Hepatitis B panel Clinical guideline recommendation ACR guidelines
Failed DMARD trials Step therapy documentation Medical records
Disease activity scores Medical necessity evidence Clinical assessment
ICD-10 codes Diagnosis verification (M06.9 - RA) Billing records

Key Lab Results

  • Tuberculosis screening: Negative QuantiFERON Gold, chest X-ray clear
  • Hepatitis B: Negative HBsAg, immune from vaccination
  • Inflammatory markers: Elevated ESR (45 mm/hr) and CRP (12.3 mg/L)

Prior Treatment History

  1. Methotrexate 25mg weekly (6 months) - inadequate response, mild nausea
  2. Sulfasalazine 2g daily (4 months) - minimal improvement, discontinued due to GI intolerance
  3. Prednisone tapers - temporary relief only
From our advocates: We've seen that the most successful prior authorizations include specific dates, dosages, and documented reasons for discontinuation of each prior therapy. Generic phrases like "failed multiple DMARDs" often result in denials.

Submission Process

Dr. Chen submitted Maria's prior authorization through UnitedHealthcare's provider portal on March 15th. The submission included:

PA Submission Contents

Medical Necessity Letter Highlights:

  • Diagnosis: Moderately to severely active rheumatoid arthritis (ICD-10: M06.9)
  • Failed conventional DMARDs as documented above
  • Negative TB and hepatitis B screening
  • Patient unable to work due to disease activity
  • Enbrel prescribed at standard dose (50mg weekly subcutaneous)

Supporting Documents:

Portal Submission Steps

  1. Login to UHC provider portal
  2. Navigate to Prior Authorization section
  3. Select Enbrel (etanercept) from drug list
  4. Upload all supporting documentation
  5. Submit and note confirmation number: PA-2024-0315-MC

Expected timeline: 5-7 business days for standard review

Initial Outcome: The Denial

On March 22nd, UnitedHealthcare denied the prior authorization. The denial letter stated:

Denial Reason: "Member has not tried and failed a preferred TNF inhibitor biosimilar as required by step therapy protocol."

Specific requirements cited:

  • Must try Amjevita (adalimumab biosimilar) or Inflectra (infliximab biosimilar)
  • Duration of trial: minimum 3 months at therapeutic dose
  • Documentation of inadequate response or intolerance required

This denial was frustrating but not uncommon. UnitedHealthcare's step therapy requirements often prioritize biosimilars over brand biologics for cost containment.

The Appeal Strategy

Rather than starting a biosimilar trial that could delay treatment by months, Dr. Chen and Maria decided to appeal based on medical necessity and patient-specific factors.

Internal Appeal Preparation

New evidence gathered:

  • Detailed letter explaining why biosimilar delay would be detrimental
  • Updated disease activity scores showing progression
  • Literature supporting Enbrel's efficacy profile for Maria's specific RA presentation
  • Patient impact statement about work disability

Appeal submission: March 29th via UnitedHealthcare appeals portal

Peer-to-Peer Review

Dr. Chen requested a peer-to-peer review with UnitedHealthcare's medical director. During the 20-minute call on April 5th, key discussion points included:

  • Maria's rapid disease progression despite optimal conventional DMARD therapy
  • Risk of irreversible joint damage with further treatment delays
  • Patient's occupation requiring fine motor skills (teaching, writing)
  • Clinical rationale for immediate TNF inhibitor therapy

The medical director was receptive but noted that policy exceptions required additional documentation.

Resolution: Approval at Last

On April 12th, UnitedHealthcare approved Enbrel for Maria with the following terms:

Approval Details

Coverage approved for: 12 months
Quantity limit: 4 prefilled syringes per month (50mg weekly)
Pharmacy requirement: OptumRx specialty pharmacy
Prior authorization ID: PA-2024-0412-AP
Copay: $75/month (Tier 4 specialty)

Conditions of approval:

  • Must be prescribed by rheumatologist
  • No concurrent use with other biologics
  • Annual reauthorization required with documentation of clinical response

Financial Assistance

Maria also enrolled in the Enbrel Support program which reduced her copay to $10/month, making the treatment financially accessible.

When traditional insurance coverage falls short, Counterforce Health helps patients like Maria by transforming denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and payer policies to draft point-by-point rebuttals that significantly improve approval rates.

What We'd Do Differently

Reflecting on Maria's journey, several strategies could have expedited approval:

Proactive Strategies

  1. Submit biosimilar contraindication upfront: If patient has specific reasons to avoid biosimilars (allergies, prior reactions), document this in initial PA
  2. Include economic impact: Quantify work disability costs and productivity loss
  3. Leverage state protections: Reference New York's patient protection laws in appeals
  4. Engage case management: Request UnitedHealthcare case manager for complex conditions

Documentation Improvements

  • More detailed prior therapy records: Include exact dates, doses, and specific adverse effects
  • Functional assessment scores: Use standardized tools like HAQ-DI for objective improvement measures
  • Imaging progression: Document joint damage progression with X-rays or MRI if available

Templates & Checklists

Prior Authorization Checklist

  • Specialist prescription (rheumatologist required)
  • ICD-10 diagnosis code (M06.9 for RA)
  • Negative TB screening within 12 months
  • Documented DMARD failures (≥3 months each)
  • Medical necessity letter with clinical rationale
  • Current lab values (inflammatory markers)
  • Patient insurance information and member ID

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about prior authorization status for Enbrel, confirmation number [PA-XXXX-XXXX]. Can you tell me the current status and any additional requirements needed for approval?"

Key questions to ask:

  • What specific documentation is missing?
  • Is there a medical director available for peer-to-peer review?
  • What are the exact step therapy requirements?
  • How do I request an expedited review if urgent?

Medical Necessity Letter Template

Essential elements to include:

  1. Patient demographics and diagnosis with ICD-10 code
  2. Disease severity and impact on function
  3. Prior treatment failures with specific details
  4. Clinical rationale for Enbrel specifically
  5. Safety screening results (TB, hepatitis B)
  6. Monitoring plan and follow-up schedule

FAQ

How long does UnitedHealthcare prior authorization take in New York?
Standard review: 5-7 business days. Expedited review for urgent cases: 72 hours. Appeals: up to 30 days for internal review.

What if Enbrel is non-formulary on my UnitedHealthcare plan?
Request a formulary exception with medical necessity documentation. Non-formulary doesn't mean uncoverable, just requires additional justification.

Can I request expedited appeal in New York?
Yes, if delay poses serious risk to health. New York allows expedited external appeals with decisions within 72 hours for urgent cases.

Does step therapy apply if I failed biosimilars outside New York?
Document prior biosimilar failures from any state. UnitedHealthcare should accept out-of-state medical records as evidence of prior therapy.

How do I file an external appeal in New York?
After exhausting UnitedHealthcare's internal appeals, file with NY Department of Financial Services within 4 months. Fee: $25 (waived for Medicaid/hardship).

What's the success rate for Enbrel appeals in New York?
While specific rates aren't published, New York's external review system has historically been patient-friendly, with many denials overturned when proper medical documentation is provided.

Can I use manufacturer copay cards with UnitedHealthcare?
Yes, the Enbrel Support program copay card can be used with most commercial insurance plans, potentially reducing copays to $10/month.

What if my rheumatologist won't help with appeals?
Contact Community Health Advocates at 888-614-5400 for free assistance with New York insurance appeals, or consider services like Counterforce Health that specialize in prescription drug appeals.

Disclaimer: 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 personalized guidance. For official New York insurance appeal information, visit the Department of Financial Services website.

Sources & Further Reading

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