By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (alectinib) Covered by UnitedHealthcare in Texas: Prior Authorization Forms, Appeals Process, and Step-by-Step Approval Guide

Answer Box: Getting Alecensa Covered by UnitedHealthcare in Texas

UnitedHealthcare requires prior authorization for Alecensa (alectinib) in Texas, with the drug placed on Tier 3 (specialty) requiring clinical documentation of ALK-positive NSCLC. Your oncologist submits the PA via UHC's provider portal with ALK test results, staging, and medical necessity letter. If denied, Texas law provides internal appeals (180 days) and binding external review through an Independent Review Organization. First step today: Contact your oncologist to request ALK testing confirmation and begin the PA submission process through the UHC Provider Portal.

Table of Contents

  1. Plan Types & Coverage Differences
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Considerations
  6. Submission Process & Forms
  7. Appeals Process in Texas
  8. Common Denial Reasons & Solutions
  9. Frequently Asked Questions

Plan Types & Coverage Differences

UnitedHealthcare operates several plan types in Texas, each with different referral and network requirements that affect your path to Alecensa coverage:

HMO Plans: Require a primary care physician (PCP) referral to see an oncologist. UHC operates regional HMO networks in Houston/Corpus Christi, Dallas/Fort Worth, and Austin/San Antonio. Without a proper referral, your oncology visits won't be covered, blocking access to Alecensa prescriptions.

PPO Plans: Offer the most flexibility—you can see an oncologist directly without referrals and have out-of-network coverage (though at higher cost). This is often the fastest path to specialty drug approval.

EPO Plans: Restrict coverage to in-network providers only but may not require referrals (plan-specific). Premiums typically fall between HMO and PPO rates.

Note: All plan types require prior authorization for Alecensa regardless of referral rules. The Texas Office of Public Insurance Counsel provides annual HMO comparison reports that can help you understand your specific plan's network adequacy.

Formulary Status & Tier Placement

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans UHC Provider Portal PA Requirements Guide
Formulary Tier Tier 3 (Specialty) OptumRx Formulary 2025 Premium Standard Formulary
Step Therapy Not explicitly required Plan documents Verify with your specific plan
Quantity Limits 30-day supply typical Specialty pharmacy Specialty Vendor List
Age Limits 18+ years FDA labeling Clinical documentation required

Alecensa is classified as a specialty medication (SP) in UnitedHealthcare's 2025 formularies, meaning higher copays and mandatory specialty pharmacy dispensing. Alternative ALK inhibitors like Alunbrig (brigatinib) are also Tier 3 with similar PA requirements.

Prior Authorization Requirements

Your oncologist must submit comprehensive documentation proving medical necessity:

Required Clinical Documentation:

  • ALK-positive test results from FDA-approved companion diagnostic (FISH, IHC, or NGS from CLIA-certified lab)
  • Pathology report confirming NSCLC with staging (metastatic/advanced or adjuvant post-resection ≥4 cm/node-positive)
  • Treatment history including prior therapies, failures, or contraindications
  • NCCN guideline citations supporting Alecensa use
  • Physician letter detailing medical necessity and treatment rationale
Clinician Corner: Your medical necessity letter should address the specific indication (metastatic vs. adjuvant), patient's performance status (ECOG 0-2), and why Alecensa is preferred over formulary alternatives. Include references to NCCN Category 1 recommendations for ALK-positive NSCLC.

Specialty Pharmacy Network

UnitedHealthcare mandates that Alecensa be dispensed through designated specialty pharmacies to maintain proper handling and patient monitoring:

Approved Specialty Pharmacies:

  • Optum Specialty Pharmacy (primary option)
  • Biologics
  • Walgreens Specialty Pharmacy

Your oncologist selects the specialty pharmacy during PA submission. Upon approval, the chosen pharmacy contacts you for enrollment, insurance verification, and coordination with manufacturer copay assistance programs.

Patient Enrollment Process:

  1. Gather insurance card, ALK test results, and current medication list
  2. Provider submits PA via UHC Provider Portal
  3. Specialty pharmacy contacts patient for enrollment
  4. Coordinate with Genentech Access Solutions for copay assistance if needed

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Patient: Contact oncologist to request ALK testing confirmation and treatment history documentation
  2. Provider: Log into UHC Provider Portal and access Prior Authorization tool
  3. Provider: Download state-specific Alecensa PA form (verify current Texas version)
  4. Provider: Submit complete documentation including ALK results, pathology, NCCN citations, and medical necessity letter
  5. Provider: Select Optum Specialty Pharmacy for dispensing
  6. Follow-up: Check status via portal; call 1-800-711-4555 for urgent cases
  7. Patient: Await specialty pharmacy contact for enrollment upon approval

Timeline Expectations:

  • Standard PA review: Up to 45 days
  • Urgent/expedited: 72 hours for life-threatening cases
  • Appeals: 30 days for standard, 72 hours for expedited

Appeals Process in Texas

Texas provides robust patient protection through internal and external appeal rights:

Internal Appeals:

  • Deadline: 180 days from denial
  • Process: Submit via denial letter instructions or UHC provider portal
  • Timeline: 30 days for pre-service, 60 days for post-service
  • Expedited: 72 hours if delay would jeopardize health

External Review (Independent Review Organization):

  • Deadline: 4 months from final internal denial
  • Process: Request IRO form from UHC; submit to Texas Department of Insurance
  • Timeline: 20 days standard, 5 days for urgent cases
  • Binding: IRO decision is final and enforceable
Important: ERISA self-funded employer plans, Medicare, and Medicaid follow federal appeal rules rather than Texas state processes.

Texas Resources for Help:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing ALK test Submit FDA-approved test results Pathology report with ALK-positive confirmation
Insufficient medical necessity Strengthen clinical justification NCCN guidelines, treatment history, physician letter
Step therapy requirements Request exception based on contraindications Prior failure documentation, contraindication evidence
Non-formulary status Submit formulary exception request Clinical superiority evidence, guideline support
Incomplete prior authorization Resubmit with all required elements Complete PA form, clinical notes, lab results

Frequently Asked Questions

How long does UnitedHealthcare PA take in Texas? Standard review takes up to 45 days, but urgent cases qualify for 72-hour review if delay would jeopardize health. Cancer progression typically qualifies for expedited review.

What if Alecensa is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and superiority over formulary alternatives. Include NCCN guideline citations and treatment history.

Can I request an expedited appeal? Yes, if the standard timeline would seriously jeopardize your health or ability to regain maximum function. Your oncologist must provide clinical justification for urgency.

Does step therapy apply if I've tried other ALK inhibitors? Prior failures or contraindications to other ALK inhibitors typically qualify for step therapy exceptions. Document specific reasons why alternatives are inappropriate.

What's the cost of Alecensa without coverage? Wholesale acquisition cost is approximately $19,466 per 30-day supply. Genentech Access Solutions offers copay assistance and patient support programs.

How do I check my formulary status? Log into your UHC member portal or call member services. Formularies update January 1 and July 1 annually, so verify current status.

Counterforce Health helps patients navigate insurance denials by turning rejection letters into targeted, evidence-backed appeals. Our platform analyzes denial reasons and drafts point-by-point rebuttals aligned with payer policies, pulling the right medical citations and clinical evidence to strengthen your case. Learn more at www.counterforcehealth.org.

From Our Advocates: We've seen Alecensa approvals succeed when oncologists include complete ALK testing documentation and cite specific NCCN guideline categories in their medical necessity letters. The key is demonstrating clear clinical rationale and ensuring all required elements are submitted together rather than piecemeal.

When appealing denials, Counterforce Health can help identify the specific denial basis and craft targeted responses that address payer concerns with appropriate clinical evidence and policy citations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by your specific plan based on medical necessity and plan terms. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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