By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (Alectinib) Covered by UnitedHealthcare in Michigan: Complete Prior Authorization Guide

Answer Box: Getting Alecensa Covered by UnitedHealthcare in Michigan

UnitedHealthcare requires prior authorization for Alecensa (alectinib) in Michigan for ALK-positive NSCLC, with no step therapy requirements. Submit PA through the UnitedHealthcare Provider Portal with ALK test results, oncologist prescription, and diagnosis documentation. If denied, file internal appeal within 30 days, then external review with Michigan DIFS within 127 days. Start by gathering your ALK test results and having your oncologist submit the prior authorization today.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Clinician Corner: Medical Necessity Documentation
  4. Common Denial Reasons & Solutions
  5. Appeals Process in Michigan
  6. Patient Scripts & Templates
  7. Cost Savings Options
  8. When to Escalate
  9. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Alecensa prescriptions UnitedHealthcare Provider Portal OptumRx PA Criteria
ALK-Positive NSCLC Documented anaplastic lymphoma kinase positive metastatic or adjuvant NSCLC Pathology report with FISH/NGS results UHC Policy
Oncologist Prescriber Must be prescribed by an oncology specialist Provider credentialing OptumRx Criteria
No Step Therapy No prior crizotinib or other ALK inhibitor trial required Policy documentation OptumRx Guidelines
Coverage Duration 12-24 months typical approval Varies by plan type Plan-specific documents

Step-by-Step: Fastest Path to Approval

1. Confirm ALK Testing Results

Who: Patient/oncologist
Document needed: ALK FISH or NGS test results showing positive rearrangement
Timeline: If not done, 1-2 weeks for results
Source: UHC Molecular Testing Policy

2. Gather Required Documentation

Who: Clinic staff
Documents needed:

  • Pathology report confirming NSCLC diagnosis
  • Staging information (metastatic or post-surgical for adjuvant)
  • Prior therapy history and outcomes
  • Current performance status (ECOG 0-2)

3. Submit Prior Authorization

Who: Prescribing oncologist
How: UnitedHealthcare Provider Portal or call 866-889-8054
Timeline: 72 hours standard, 24 hours expedited
Required: Medical necessity letter with clinical rationale

4. Track Approval Status

Who: Patient/clinic
How: Provider portal or member services
Timeline: Decision within 3 business days
Next step: If approved, coordinate with specialty pharmacy

5. If Denied, File Internal Appeal

Who: Patient or authorized representative
Timeline: Within 30 days of denial notice
How: UHC Appeals Process
Documents: Denial letter, additional clinical evidence

6. Request Peer-to-Peer Review

Who: Prescribing oncologist
Timeline: Before or during internal appeal
How: Contact UnitedHealthcare medical director
Duration: 5-10 minute discussion of medical necessity

7. External Review (If Internal Appeal Denied)

Who: Patient
Timeline: Within 127 days of final internal denial
How: Michigan DIFS External Review
Decision: 60 days standard, 72 hours expedited with physician letter

Clinician Corner: Medical Necessity Documentation

Medical Necessity Letter Checklist

Your letter to UnitedHealthcare should include:

Patient Information:

  • Full diagnosis with ICD-10 codes (C78.00 for metastatic NSCLC)
  • ALK rearrangement confirmation with test methodology
  • Disease stage and current status
  • ECOG performance status

Clinical Rationale:

  • Why Alecensa is medically necessary for this specific patient
  • Reference to FDA labeling for ALK+ NSCLC
  • NCCN guideline support (Category 1 recommendation)
  • Expected clinical benefit and monitoring plan

Prior Therapy History:

  • Document any previous treatments and outcomes
  • Note contraindications to alternative therapies
  • Explain why step therapy doesn't apply or was unsuccessful

Dosing and Monitoring:

  • Standard 600 mg twice daily with food
  • Liver function and CPK monitoring plan
  • Duration of treatment recommendation

When dealing with coverage challenges, platforms like Counterforce Health can help clinicians generate evidence-backed appeals by analyzing denial letters and payer policies to create targeted rebuttals with appropriate citations and clinical documentation.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing ALK test Submit positive ALK results FISH or NGS report with methodology
Not medically necessary Provide clinical justification Medical necessity letter with NCCN guidelines
Experimental/investigational Reference FDA approval FDA labeling for approved indications
Step therapy required Request exception Prior therapy failure documentation or contraindications
Prescriber not qualified Verify oncologist credentials Board certification in oncology
Incomplete application Resubmit with all requirements Complete PA form with all supporting documents

Appeals Process in Michigan

Internal Appeals with UnitedHealthcare

Timeline: 30 days for pre-service denials, 60 days for post-service
How to file:

Required documents:

  • Original denial letter
  • Additional medical records
  • Updated medical necessity letter
  • Any new clinical evidence

External Review through Michigan DIFS

Michigan's Patient's Right to Independent Review Act provides strong consumer protections:

Standard External Review:

  • Timeline: 127 days from final internal denial to file
  • Decision: Within 60 days
  • How to file: DIFS External Review Form
  • Cost: Free to consumers

Expedited External Review:

  • Timeline: 72 hours for decision
  • Eligibility: Pre-service denials where delay would jeopardize health
  • Required: Physician letter confirming urgency
  • Process: Same form but marked "expedited"

Contact DIFS:

Patient Scripts & Templates

Calling UnitedHealthcare Member Services

"Hi, I'm calling about a prior authorization for Alecensa for ALK-positive lung cancer. My member ID is [ID number]. Can you tell me the status of my PA request submitted on [date]? If it's been denied, I'd like to understand the specific reason and start an internal appeal."

Requesting Peer-to-Peer Review

"This is Dr. [Name] requesting a peer-to-peer review for my patient's Alecensa denial. The patient has ALK-positive metastatic NSCLC and meets all coverage criteria. Can you schedule me with your medical director within the next few days?"

Email Template for Medical Records

"Dear [Clinic Name],

I need copies of the following medical records for my insurance appeal for Alecensa coverage:

  • ALK test results (FISH or NGS)
  • Pathology report confirming NSCLC diagnosis
  • Staging scans and reports
  • Prior treatment history and outcomes
  • Most recent oncology visit notes

Please send to [email] or fax to [number] by [date]. Thank you."

Cost Savings Options

Manufacturer Support

  • Genentech Access Solutions: genentech-access.com
  • Copay assistance: Up to $25,000 annually for eligible commercial patients
  • Patient assistance program: For uninsured or underinsured patients

Foundation Grants

Note: Medicare and Medicaid patients are not eligible for manufacturer copay assistance due to federal anti-kickback laws.

When to Escalate

Contact Michigan regulators if:

  • UnitedHealthcare violates appeal timelines
  • You're not receiving required notices
  • The insurer is not following Michigan insurance law

Michigan Department of Insurance and Financial Services (DIFS):

  • Consumer hotline: 877-999-6442
  • Online complaint: michigan.gov/difs
  • Address: P.O. Box 30220, Lansing, MI 48909

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Michigan?

Standard PA decisions are made within 72 hours for non-urgent requests and 24 hours for expedited cases. Source: UHC Provider Guidelines

What if Alecensa isn't on my UnitedHealthcare formulary?

Even non-formulary drugs can be covered with prior authorization and medical necessity documentation. The PA process evaluates clinical need regardless of formulary status.

Can I request an expedited appeal in Michigan?

Yes, both UnitedHealthcare and Michigan DIFS offer expedited reviews. For DIFS external review, you need a physician letter stating that delay would jeopardize your health.

Does step therapy apply if I haven't tried crizotinib?

For ALK-positive NSCLC, current OptumRx criteria don't require step therapy with crizotinib for Alecensa, but individual plans may vary. Check your specific plan documents.

What happens if my external review is denied?

DIFS external review decisions are binding on the insurer. If approved, UnitedHealthcare must cover the treatment. Denied external reviews generally cannot be appealed further through insurance channels.

How much does Alecensa cost without insurance?

The wholesale acquisition cost is approximately $19,466 per 240-count bottle, which typically lasts one month. Source: Drug Pricing Transparency

Can my doctor submit the appeal for me?

Yes, your physician or other authorized representative can file appeals on your behalf with your written consent. This is often more effective as they can provide clinical context.

What if I'm on Medicare Advantage with UnitedHealthcare?

Medicare Advantage appeals follow similar timelines but may have additional federal protections. You still have access to Michigan's external review process for most denials.

From Our Advocates: We've seen many Michigan patients successfully obtain Alecensa coverage after initial denials by ensuring their ALK test results were properly documented and their oncologist provided a detailed medical necessity letter referencing NCCN guidelines. The key is often in the clinical details—staging information, prior therapy history, and performance status can make the difference between approval and denial.

Navigating insurance coverage for specialty medications like Alecensa can feel overwhelming, but Michigan patients have strong appeal rights and multiple pathways to access needed treatments. Counterforce Health helps patients and providers turn insurance denials into successful appeals by analyzing payer policies and generating evidence-backed documentation that addresses specific denial reasons.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For official Michigan insurance regulations and appeal procedures, visit michigan.gov/difs.

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