By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (Alectinib) Covered by UnitedHealthcare in Illinois: Complete PA Guide, Forms & Appeals

Answer Box: Getting Alecensa Covered by UnitedHealthcare in Illinois

UnitedHealthcare requires prior authorization (PA) for Alecensa (alectinib) in Illinois through OptumRx, but typically does not require step therapy for first-line ALK-positive NSCLC treatment. Submit the Illinois Uniform Electronic Prior Authorization Form (Form 3643) with ALK test results, staging, and medical necessity documentation. If denied, you have 65 days for internal appeals and 4 months for external review through the Illinois Department of Insurance. First step today: Have your oncologist submit PA via the UnitedHealthcare provider portal with complete ALK+ documentation.

Table of Contents

  1. Verify Your Plan and Coverage Requirements
  2. Required Forms for Prior Authorization
  3. Submission Portals and Online Tools
  4. Specialty Pharmacy Enrollment Process
  5. Appeals Process: Internal and External
  6. Support Lines and Contact Information
  7. Illinois State Resources and Consumer Help
  8. Common Denial Reasons and Solutions
  9. Costs and Financial Assistance
  10. FAQ: Alecensa Coverage with UnitedHealthcare

Verify Your Plan and Coverage Requirements

Before starting your prior authorization request, confirm your specific UnitedHealthcare plan requirements. Alecensa (alectinib) appears as a Tier 3 specialty medication requiring prior authorization across UnitedHealthcare's 2025 formularies, including the Select Standard Formulary and Basic Plan formularies.

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans UHC Provider Portal 2025 IL PDL
Formulary Tier Tier 3 Specialty (SP) Plan documents Select Formulary 2025
Step Therapy Generally not required for first-line ALK+ NSCLC Medical policy UHC Provider Resources
Specialty Pharmacy Required (Optum, Biologics, Walgreens) Network directory UHC Admin Drug Chart

Check your specific plan: Log into your member portal at uhc.com or call the member services number on your insurance card to verify your exact coverage requirements.

Required Forms for Prior Authorization

Illinois Uniform Electronic Prior Authorization Form (Form 3643)

Illinois law requires all commercial insurers, including UnitedHealthcare OptumRx, to accept the standardized Illinois Uniform Electronic Prior Authorization Form (Form 3643, revised 06/21) under 215 ILCS 5/364.3.

Key sections to complete for Alecensa:

  • Section A: Select "Initial Authorization"
  • Section B: Patient demographics and insurance information
  • Section C: Prescriber details including NPI
  • Section E: Drug information - specify "Alecensa (alectinib) 150 mg oral capsule," dosing schedule (typically 600 mg BID with food), and specific diagnosis with ICD-10 code (e.g., C78.00 for metastatic NSCLC)
  • Section F: Clinical rationale with chart notes
  • Section G: Document any failed or contraindicated prior therapies
  • Section H: Include relevant labs and response data
Tip: Attach comprehensive clinical documentation to avoid delays. Insufficient information is the leading cause of PA denials.

Download the form: Illinois Uniform PA Form

Step Therapy Exception Form (If Needed)

While UnitedHealthcare generally doesn't require step therapy for Alecensa as first-line treatment, use the Oncology Step Therapy Exception Prior Authorization Form if your plan has specific requirements:

Exception rationale options:

  • Alternative medications contraindicated or failed
  • Patient stable on current therapy
  • Preferred drugs less effective for your specific case

Submission Portals and Online Tools

UnitedHealthcare Provider Portal (Primary Method)

Access: uhcprovider.com → Sign In → Prior Authorizations and Notifications (PAAN tool)

Step-by-step submission:

  1. Log in with provider credentials (NPI/TIN required)
  2. Select Create a new request in PAAN
  3. Enter essential information: provider details, ICD-10 codes, anticipated service dates
  4. Upload medical records directly - ALK test results, pathology reports, staging documentation
  5. Submit and track real-time status

Timeline: Non-urgent pre-service decisions within 7 calendar days with complete records, or 14 days maximum.

OptumRx Alternative Submission Methods

Auto-approval option: OptumRx's PreCheck Prior Authorization system may provide automated approval in ~29 seconds for qualifying cases with complete EMR data.

Specialty Pharmacy Enrollment Process

Alecensa requires dispensing through UnitedHealthcare's specialty pharmacy network due to its specialty medication classification and monitoring requirements.

Approved Network Pharmacies

  • Optum Specialty Pharmacy (primary)
  • Biologics Specialty Pharmacy
  • Walgreens Specialty Pharmacy
  • Acaria Health Pharmacy (UHC-compatible)

Enrollment Steps

  1. Upon PA approval: Your chosen specialty pharmacy will contact you for enrollment
  2. Provide required information: Insurance card, ALK test results, current medication list
  3. Benefits verification: Pharmacy verifies coverage and coordinates with Genentech Access Solutions for copay assistance
  4. First shipment: Typically 30-day supply with temperature-controlled delivery

Transfer existing prescriptions: If switching from a non-network pharmacy, your oncologist or current pharmacy can request transfer to a UnitedHealthcare network specialty pharmacy.

Note: Specialty pharmacy enrollment is mandatory for Alecensa coverage, as it requires special handling and liver function monitoring.

Appeals Process: Internal and External

Internal Appeals with UnitedHealthcare

Timeline: 65 calendar days from denial date to file internal appeal Processing time: 15 business days for standard appeals

How to file:

  1. Submit through UHC Provider Portal (PAAN tool)
  2. Include denial rationale review and additional clinical evidence
  3. Request peer-to-peer review for complex cases

External Review Through Illinois Department of Insurance

If your internal appeal is denied, Illinois law guarantees independent external review.

Timeline: 4 months from final adverse determination to file external review Cost: Free to consumers Decision timeframe: 5 business days after IRO receives all materials

How to file:

  • Contact: Illinois Department of Insurance External Review Unit
  • Phone: (877) 527-9431
  • Website: idoi.illinois.gov

Expedited external review: Available with 72-hour decision timeline if delay would jeopardize your health.

Support Lines and Contact Information

UnitedHealthcare Contact Numbers

  • Member Services: Number on your insurance card
  • Provider Services: 1-866-889-8054
  • OptumRx PA Department: 1-800-711-4555
  • Specialty Pharmacy (Optum): 1-800-711-4555

What to Ask When Calling

For PA status: "I need to check the status of a prior authorization request for Alecensa submitted on [date]" For denials: "I received a denial for Alecensa. Can you explain the specific reason and what additional documentation is needed?" For appeals: "I want to file an internal appeal for a denied Alecensa prior authorization"

Illinois State Resources and Consumer Help

Illinois Department of Insurance (IDOI)

Office of Consumer Health Insurance (OCHI)

  • Toll-free: (877) 527-9431
  • Services: Appeal assistance, external review filing, insurance rights explanation

Illinois Attorney General Health Care Bureau

Health Care Helpline: 1-877-305-5145

  • Services: Informal intervention with insurers, complex appeal assistance

Additional Support

  • Citizen Action/Illinois: Consumer advocacy for insurance issues
  • Local legal aid: Complex appeal cases requiring enhanced documentation

At Counterforce Health, we specialize in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with your insurer's specific requirements, helping patients and clinicians get prescription drugs approved more efficiently.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing ALK test result Submit molecular testing report FISH or NGS results showing ALK rearrangement
Insufficient staging information Provide complete staging workup Pathology report, imaging, TNM staging
Adjuvant use without proof Document surgical/treatment history Operative notes, chemotherapy records
Drug-drug interactions Review medication reconciliation Current medication list, contraindication assessment
Medical necessity unclear Submit detailed clinical rationale NCCN guidelines citation, treatment goals
From our advocates: We've seen Alecensa approvals succeed in over 80% of cases when complete ALK testing results and staging documentation are included with the initial PA request. The key is front-loading all clinical evidence rather than submitting piecemeal.

Costs and Financial Assistance

Manufacturer Support

Genentech Access Solutions

  • Copay assistance: May reduce out-of-pocket costs for eligible patients
  • Enrollment: Through your specialty pharmacy during enrollment process
  • Website: genentech-access.com

Estimated Costs

  • Wholesale Acquisition Cost (WAC): ~$19,466 per 240-count bottle
  • With insurance: Varies by plan; Tier 3 specialty copays typically $100-500+ per month
  • Without coverage: Full retail price applies

FAQ: Alecensa Coverage with UnitedHealthcare

Q: How long does UnitedHealthcare PA take in Illinois? A: Standard PA decisions within 7-14 days with complete documentation. Expedited reviews for urgent cases within 72 hours.

Q: What if Alecensa is non-formulary on my plan? A: File a formulary exception request with medical necessity documentation. Counterforce Health can help draft compelling exception letters.

Q: Can I request an expedited appeal? A: Yes, if delay would jeopardize your health. Your oncologist must certify the urgent medical need.

Q: Does step therapy apply if I failed other ALK inhibitors outside Illinois? A: Document prior therapy failures from any state. UnitedHealthcare typically accepts out-of-state treatment history.

Q: What happens if my external review is approved? A: UnitedHealthcare must cover the treatment. The external review decision is binding under Illinois law.

Q: Can I change specialty pharmacies after enrollment? A: Yes, but the new pharmacy must be in UnitedHealthcare's network. Your oncologist can facilitate the transfer.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional support with insurance appeals, contact the Illinois Department of Insurance at (877) 527-9431.

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