By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (chenodiol) Approved by UnitedHealthcare in Pennsylvania: Complete PA Guide with Appeals Process

Quick Answer: Getting Chenodal Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Chenodal (chenodiol) with mandatory step therapy through ursodiol first. In Pennsylvania, you have strong appeal rights including a new state-run external review program with a 50% overturn rate. Start today by: 1) Confirming your plan covers specialty drugs through OptumRx, 2) Gathering imaging showing radiolucent gallstones and ursodiol trial documentation, 3) Submitting the OptumRx PA form via fax to 1-844-403-1027. If denied, Pennsylvania's external review program gives you four months to appeal with independent physician review.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Understanding Typical Timelines
  7. If You Need More Information
  8. If Your Request is Denied
  9. Pennsylvania's External Review Advantage
  10. Renewal and Reauthorization
  11. Cost Savings and Patient Support
  12. Quick Reference Checklist
  13. Frequently Asked Questions

What This Guide Covers

This guide helps Pennsylvania patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Chenodal (chenodiol), a bile acid medication used primarily for dissolving radiolucent gallstones in patients who cannot undergo surgery.

Chenodal, manufactured by Travere Therapeutics, faces significant coverage barriers due to its specialty status and UnitedHealthcare's strict step therapy requirements. However, Pennsylvania residents have unique advantages in the appeals process that can significantly improve approval odds.

Who this helps: Patients with radiolucent gallstones who've failed or can't tolerate ursodiol, those with cerebrotendinous xanthomatosis (CTX), and healthcare providers seeking efficient PA submission strategies.

Before You Start: Verify Your Coverage

Check Your Plan Type

UnitedHealthcare processes Chenodal through different pathways depending on your plan:

  • Commercial plans: Managed by OptumRx with standard PA requirements
  • Medicare Advantage: Stricter criteria with ~9% denial rate for specialty drugs
  • Medicaid (if applicable): State-specific requirements may apply

Confirm Formulary Status

Chenodal typically sits on Tier 3 (non-preferred brand) or specialty tier, requiring:

  • Prior authorization for all uses
  • Step therapy through ursodiol for gallstone indications
  • Specialty pharmacy dispensing
Tip: Log into your UnitedHealthcare member portal to verify your specific formulary and copay tier before starting the PA process.

Gather Required Documentation

Essential Clinical Documentation

For Radiolucent Gallstones:

  • Ultrasound report confirming radiolucent (cholesterol) stones ≤20mm
  • Ursodiol trial documentation: dates, duration, reason for failure/intolerance
  • ICD-10 codes: K80.20 (gallbladder calculus without cholecystitis) or appropriate variant
  • Surgical contraindication notes: why cholecystectomy isn't appropriate

For Cerebrotendinous Xanthomatosis:

  • Genetic testing confirming CYP27A1 pathogenic variant
  • Specialist consultation (endocrinologist, neurologist, geneticist)
  • Clinical response documentation for renewals

Required Forms and Submissions

The primary form is the OptumRx Prior Authorization Request Form. Complete all sections including:

  • Patient demographics and insurance information
  • Prescriber details with NPI number
  • Medication specifics: Chenodal/chenodiol with exact dosing
  • Clinical justification with supporting documentation

Submit Your Prior Authorization Request

Submission Methods

Primary: Fax to 1-844-403-1027 (non-urgent requests) Electronic: CoverMyMeds platform for faster processing Urgent: Call 1-800-711-4555 for expedited review

Clean Request Packet Checklist

✓ Completed OptumRx PA form with all required fields ✓ Imaging reports (ultrasound showing radiolucent stones) ✓ Prior therapy documentation (ursodiol trial/failure) ✓ Clinical notes supporting medical necessity ✓ Prescriber attestation of surgical contraindication ✓ Current lab values if relevant to monitoring

Note: According to UnitedHealthcare's step therapy policy, ursodiol trial failure documentation is mandatory for gallstone indications.

Follow-Up and Tracking

When to Call

  • Day 3: Confirm receipt of your submission
  • Day 10: Check processing status if no response
  • Day 15: Escalate if approaching deadline

Sample Call Script

"Hi, I'm calling to check the status of a prior authorization for Chenodal for [patient name], member ID [number], submitted on [date]. The reference number is [if available]. Can you provide an update on the review timeline?"

Document all interactions with reference numbers and representative names.

Understanding Typical Timelines

Standard Processing

  • Commercial plans: 72 hours after complete submission
  • Urgent/expedited: 24-72 hours
  • Medicare Advantage: Up to 14 days for standard review

Pennsylvania-Specific Considerations

Pennsylvania's insurance regulations require insurers to process PA requests within reasonable timeframes, typically aligning with federal standards but with additional consumer protections through the state's external review program.

If You Need More Information

Common Information Requests

UnitedHealthcare may request additional documentation for:

  • Clinical rationale: Why Chenodal vs. alternatives
  • Imaging clarification: Confirming stone composition
  • Prior therapy details: Specific ursodiol dosing and duration tried
  • Monitoring plans: Liver function test scheduling

Medical Necessity Letter Elements

Healthcare providers should include:

  • Patient's specific diagnosis with ICD-10 code
  • Complete prior therapy history with outcomes
  • Clinical rationale for Chenodal selection
  • Treatment goals and monitoring plan
  • Supporting literature citations (FDA labeling, clinical guidelines)

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
No ursodiol trial Document previous therapy Prescription records, clinical notes
Off-label use Provide compendia support FDA labeling, peer-reviewed studies
Imaging insufficient Submit detailed reports Ultrasound with stone characterization
Surgical candidate Document contraindications Risk assessment, specialist consultation

Internal Appeal Process

You have 180 days from denial to file an internal appeal with UnitedHealthcare. Submit:

  • Original denial letter
  • Additional clinical documentation
  • Updated medical necessity letter
  • Any new supporting literature

Counterforce Health specializes in transforming insurance denials into targeted, evidence-backed appeals. Their platform can help identify the specific denial basis and draft point-by-point rebuttals aligned to UnitedHealthcare's own coverage criteria, significantly improving your chances of approval.

Pennsylvania's External Review Advantage

New State Program Benefits

Pennsylvania launched its Independent External Review Program in January 2024, offering significant advantages over the federal process:

  • 50% overturn rate in the program's first year
  • State oversight rather than federal delegation
  • Clear timelines: 45 days standard, 72 hours expedited
  • Additional evidence allowed: 15 days to submit supporting materials

How to Access External Review

  1. Exhaust internal appeals and receive Final Adverse Benefit Determination
  2. File within 4 months through Pennsylvania Insurance Department
  3. Submit online at pa.gov or by mail/fax using PID forms
  4. Independent physician review by assigned IRO
From our advocates: "We've seen Pennsylvania's external review program consistently favor patients when insurers deny rare disease medications without proper clinical consideration. The key is presenting clear evidence of medical necessity and prior therapy failures in an organized, physician-friendly format."

Pennsylvania Resources

  • Pennsylvania Insurance Department Consumer Services: Available for guidance throughout the process
  • Pennsylvania Health Law Project: Free assistance for complex appeals
  • Pennie marketplace support: For ACA plan-related issues

Renewal and Reauthorization

Planning Ahead

Chenodal authorizations typically last 12 months. Calendar renewal 30-45 days before expiration with:

  • Updated clinical assessment
  • Treatment response documentation
  • Continued medical necessity justification
  • Current liver function tests

Evidence for Renewal

  • Gallstone cases: Imaging showing stone dissolution progress
  • CTX cases: Clinical stability or improvement markers
  • Safety monitoring: Normal liver function tests
  • Adherence documentation: Prescription fill history

Cost Savings and Patient Support

Travere Therapeutics Support Programs

TotalCare Hub (833-345-7727) offers:

  • Copay assistance: Potentially $0 out-of-pocket for commercial insurance
  • Patient assistance program: Free medication for eligible uninsured patients
  • Insurance navigation: Help with PA submissions and appeals
Important: Medicare beneficiaries cannot use manufacturer copay cards but may qualify for needs-based free drug programs.

Coverage Gap Considerations

For UnitedHealthcare Medicare plans, patients may face coverage gaps (donut hole) where out-of-pocket costs increase. Counterforce Health can help identify alternative coverage pathways and appeal strategies specific to Medicare Advantage utilization management practices.

Quick Reference Checklist

Before Submitting:

  • Verify specialty pharmacy network requirements
  • Confirm ursodiol trial documentation complete
  • Obtain current ultrasound confirming radiolucent stones
  • Complete OptumRx PA form entirely
  • Gather prescriber NPI and contact information

After Submission:

  • Document submission date and method
  • Set follow-up reminders (days 3, 10, 15)
  • Prepare appeal materials in case of denial
  • Contact Travere TotalCare for patient support enrollment

Frequently Asked Questions

How long does UnitedHealthcare PA take in Pennsylvania? Standard processing is 24-72 hours after complete submission. Urgent requests may be processed within 24 hours.

What if Chenodal is non-formulary on my plan? Non-formulary medications require additional justification showing medical necessity and lack of suitable formulary alternatives.

Can I request an expedited appeal? Yes, if your condition poses an urgent health threat. Document the urgency with clinical evidence.

Does step therapy apply if I failed ursodiol outside Pennsylvania? Yes, UnitedHealthcare's step therapy requirements apply regardless of where prior therapy was tried, as long as it's properly documented.

What happens if my external review is approved? UnitedHealthcare must immediately provide coverage, including retroactive coverage if you paid out-of-pocket during the appeal.

Can my doctor request a peer-to-peer review? Yes, providers can request peer-to-peer discussions during the PA or appeal process to discuss clinical rationale directly with UnitedHealthcare medical directors.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with healthcare providers or insurance representatives. Coverage decisions depend on individual plan benefits, clinical circumstances, and current policy interpretations. Always verify current requirements with your insurer and healthcare team.

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