By Counterforce Health Team in Berinert (C1-esterase inhibitor, IV) —

How to Get Berinert (C1-esterase inhibitor, IV) Covered by UnitedHealthcare in New York: Complete Guide with Forms, Appeals, and Support Resources

Answer Box: Quick Path to Berinert Coverage

To get Berinert (C1-esterase inhibitor, IV) covered by UnitedHealthcare in New York: Submit prior authorization through OptumRx with confirmed HAE diagnosis (C1-INH deficiency labs or genetic variants), prescribed by immunologist/allergist for acute attacks only. Use CoverMyMeds for electronic PA or fax to 1-844-403-1027. If denied, request peer-to-peer review within 24 hours, then file internal appeal via UHC Provider Portal within 180 days. New York residents can pursue external appeal through DFS within 4 months of final denial ($25 fee, refunded if overturned).

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Options
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Network & Home Infusion
  6. Support Phone Lines & What to Ask
  7. New York External Appeals & Consumer Help
  8. Appeals Playbook: Internal to External
  9. Common Denial Reasons & How to Fix Them
  10. Frequently Asked Questions

Start Here: Verify Your Plan & Find Forms

Before submitting your Berinert prior authorization, confirm your UnitedHealthcare plan type and locate the current forms:

Plan Verification Steps:

  1. Check your insurance card for "OptumRx" (pharmacy benefit manager)
  2. Log into UHC Provider Portal to verify specialty drug coverage
  3. Confirm you have a New York address on file for state-specific appeal rights

Current Policy & Forms:

Prior Authorization Forms & Requirements

Coverage Criteria for Berinert (2025 Program 2211-6)

Initial Authorization (12 months):

  • Confirmed HAE diagnosis via:
    • Type I/II HAE: C1-INH antigenic OR functional level below normal laboratory standard
    • HAE with normal C1-INH: Genetic variants (factor XII, angiopoietin-1, plasminogen-1, kininogen-1, myoferlin, or heparan sulfate-glucosamine 3-O-sulfotransferase 6)
  • Prescribed for acute HAE attacks only (not prophylaxis)
  • Prescribed by immunologist or allergist
  • Not used concurrently with Firazyr or Ruconest

Reauthorization Requirements:

  • Documented positive clinical response to Berinert
  • Continued acute treatment indication
  • Same prescriber specialty requirement
Tip: UnitedHealthcare may approve requests based on prior claim history and ICD-10 codes through automated processes, even without meeting all traditional criteria.

Submission Portals & Electronic Options

CoverMyMeds Portal:

  • Visit CoverMyMeds OptumRx forms
  • Select "Berinert" from specialty drug list
  • Complete member details, diagnosis (ICD-10: D84.1), and prior therapy history
  • Upload supporting documents (labs, clinic notes, denial letters)

OptumRx PreCheck:

  • Automated approval for qualifying requests (~29 seconds if criteria met)
  • Integrated with major EMR systems for seamless submission

UHC Provider Portal:

  • Log in at uhcprovider.com
  • Navigate to "Prior Auth & Advance Notification"
  • Use TrackIt system for real-time status updates

Fax Numbers & Mailing Addresses

OptumRx Submission Contacts

Standard Prior Authorization:

  • Fax: 1-844-403-1027
  • Include complete member information, prescriber details, and clinical documentation

Urgent/Expedited Requests:

  • Phone: 1-800-711-4555
  • Required for life-threatening laryngeal HAE attacks
  • 72-hour decision timeline for urgent cases

Cover Sheet Tips:

  • Include member name, ID number, and New York address
  • Mark "URGENT" for laryngeal attacks or imminent health risk
  • Reference "Berinert C1-esterase inhibitor for HAE" clearly
  • Attach physician attestation for medical necessity

Specialty Pharmacy Network & Home Infusion

UnitedHealthcare-Approved Home Infusion Providers in New York

Provider Phone Services Notes
Amber Specialty Pharmacy 888-370-1724 Nationwide, NY-covered Handles Berinert-like biologics
KabaFusion 800-435-3020 Home infusion in NY IVIG/biologics support
Option Care 866-827-8203 NY home infusion Verify Berinert availability
Optum Infusion Services 877-306-4036 UHC-affiliated Direct billing capability
Soleo Health 833-765-3648 Home infusion services Specialty drug delivery

Home Infusion Requirements (Effective July 1, 2024):

  • Must use in-network providers for NY situs groups
  • Providers handle prior authorization support
  • Self-infusion training included
  • Emergency backup protocols for laryngeal attacks

Infusion Center Options

UHS Binghamton Infusion Center:

  • Address: 10-42 Mitchell Ave, Krembs 6th Floor, Binghamton, NY
  • Phone: 607-763-5855 (prior auth: 607-763-5985)
  • Hours: Mon-Fri 7am-7pm, weekends 8am-4pm

Support Phone Lines & What to Ask

Key Contact Numbers

Member Services: 1-800-624-8822

  • Verify benefits and formulary status
  • Check prior authorization status
  • Request denial letters and appeal forms

Provider Services: 1-877-842-3210

  • Clinical questions and peer-to-peer requests
  • Expedited review requests
  • Appeal submission guidance

OptumRx Specialty: 1-800-711-4555

  • Specialty drug prior authorizations
  • Home infusion coordination
  • Urgent medication needs

Questions to Ask

When Calling Member Services:

  • "Is Berinert covered under my pharmacy benefit?"
  • "What tier is Berinert on my formulary?"
  • "Do I need prior authorization for acute HAE treatment?"
  • "What's my current prior authorization status?"

When Requesting Peer-to-Peer:

  • "I need to schedule a peer-to-peer review for Berinert denial"
  • "Can you expedite this for a patient with laryngeal HAE attacks?"
  • "What clinical information should I prepare for the medical director?"

New York External Appeals & Consumer Help

New York Department of Financial Services (DFS) External Appeal

Eligibility: Available after exhausting UnitedHealthcare's internal appeal process for denials based on:

  • Medical necessity
  • Experimental/investigational treatment
  • Non-formulary drugs
  • Out-of-network services

Filing Requirements:

  • Submit within 4 months of final internal denial
  • Use DFS External Appeal Portal
  • Include physician attestation form (mandatory)
  • Fee: $25 (waived for Medicaid; refunded if overturned)

Timeline:

  • Standard: 30 days
  • Expedited: 72 hours (urgent medical needs)
  • Non-formulary drugs: 24 hours

Free Consumer Assistance

Community Health Advocates (CHA):

  • Phone: 888-614-5400
  • Free counseling on insurance denials and appeals
  • Assistance with DFS external appeal filing

Healthcare Appeals Ombudsman (New 2025):

  • Phone: 1-800-NYS-APPEAL
  • Free guidance under March 2025 reform law
  • 72-hour urgent resolution with penalties for delays

Appeals Playbook: Internal to External

Step-by-Step Appeal Process

1. Peer-to-Peer Review (First Step)

  • Request within 24 hours of denial
  • 5-10 minute call with UHC medical director
  • Present clinical rationale and HAE attack severity
  • Timeline: Inpatient within 3 business days, outpatient within 21 days

2. Level 1 Internal Appeal

  • Submit within 180 days via UHC Provider Portal
  • Include denial letter, medical records, medical necessity letter
  • Address specific denial reasons (step therapy, diagnosis documentation)
  • Timeline: 10-15 business days standard, expedited if urgent

3. Level 2 Internal Appeal

  • File within 60 days of Level 1 denial
  • Add new evidence (specialist consults, additional studies)
  • Timeline: 15-20 business days

4. New York External Appeal

  • File with DFS within 4 months of final internal denial
  • Independent medical expert review
  • Decision is binding on UnitedHealthcare

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Use for prophylaxis Emphasize acute attack treatment only Attack frequency logs, ER visits for HAE
Missing HAE documentation Provide complete diagnostic workup C1-INH levels, C4 levels, genetic testing
Quantity limits per attack Justify weight-based dosing Patient weight, 20 IU/kg calculation, FDA label
Site-of-care restrictions Document home infusion medical necessity Training completion, emergency backup plan
Step therapy requirement Document contraindications to alternatives Allergy history, prior treatment failures

Medical Necessity Letter Checklist

Essential Elements:

  • HAE diagnosis with lab confirmation
  • Attack frequency and anatomical locations
  • Prior therapy failures or contraindications
  • Berinert dosing rationale (20 IU/kg IV)
  • Self-administration training plan
  • Emergency protocol for laryngeal attacks

When navigating complex insurance appeals for specialty medications like Berinert, many patients and providers benefit from expert guidance. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take for Berinert in New York? A: Standard decisions take 72 hours. Urgent cases (life-threatening laryngeal attacks) receive expedited review, typically within 24-48 hours.

Q: What if Berinert is non-formulary on my plan? A: File a formulary exception request with medical necessity documentation. If denied, you can appeal through New York's external appeal process for non-formulary drug decisions within 24 hours.

Q: Can I get expedited appeals for HAE attacks? A: Yes. Laryngeal HAE attacks qualify for expedited internal appeals and 24-hour external appeals through New York DFS due to life-threatening nature.

Q: Does step therapy apply if I've tried other HAE treatments outside New York? A: Document all prior therapies with dates, doses, and outcomes. UnitedHealthcare accepts out-of-state treatment history with proper clinical documentation.

Q: What's the cost of Berinert without insurance approval? A: Cash price per vial is often in five figures. Contact CSL Behring patient support for copay assistance and foundation grant programs.

Q: Can I appeal if my doctor isn't an immunologist or allergist? A: UnitedHealthcare requires specialist prescribing. If your current doctor isn't a specialist, request a referral or have them coordinate with an immunologist/allergist for prescription.

Q: How do I track my appeal status? A: Use UHC Provider Portal's TrackIt system for real-time updates. For external appeals, contact DFS at 1-800-400-8882.

Q: What happens if I need Berinert while my appeal is pending? A: For urgent laryngeal attacks, go to the emergency room immediately. Hospital administration is covered without prior authorization. Request expedited appeal review citing imminent health risk.

The appeals process can feel overwhelming, but New York residents have strong protections and multiple avenues for overturning insurance denials. Counterforce Health helps patients and clinicians navigate these complex processes by identifying specific denial reasons and crafting targeted responses with the right clinical evidence and regulatory citations.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or the New York Department of Financial Services at 1-800-400-8882.

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