By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Approved by UnitedHealthcare in Ohio: Complete Prior Authorization Guide

Quick Answer: Getting Cresemba Approved in Ohio

Cresemba (isavuconazole) requires prior authorization from UnitedHealthcare in Ohio and follows step therapy requirements. You'll need documented invasive aspergillosis or mucormycosis diagnosis, infectious disease consultation, and proof that voriconazole failed or is contraindicated. Submit through the UnitedHealthcare Provider Portal or fax to 1-844-403-1027. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance. Start by confirming your formulary tier and gathering diagnostic documentation.

Table of Contents

What This Guide Covers

This guide helps patients and healthcare providers navigate UnitedHealthcare's prior authorization process for Cresemba (isavuconazole) in Ohio. Whether you're dealing with invasive aspergillosis or mucormycosis, we'll walk you through each step—from initial submission to appeals if needed.

Cresemba is a specialty antifungal medication that costs approximately $1,620 per 14-capsule bottle at wholesale prices, making insurance approval essential for patient access. The good news? With proper documentation and understanding of UnitedHealthcare's requirements, most medically appropriate requests can be approved.

Before You Start: Coverage Verification

Step 1: Confirm Your Plan Type

UnitedHealthcare operates different plan types in Ohio, each with slightly different processes:

  • Commercial plans (employer-sponsored)
  • Medicare Advantage
  • Medicaid managed care
  • Individual marketplace plans

Call the member services number on your insurance card to confirm which type you have and verify that prior authorization is required for Cresemba.

Step 2: Check Formulary Status

Cresemba is typically classified as a Tier 4 specialty medication on UnitedHealthcare formularies. This means:

  • Higher copayment or coinsurance
  • Mandatory prior authorization
  • Specialty pharmacy dispensing requirement (usually OptumRx)
  • Step therapy protocols may apply

Step 3: Verify Network Status

Ensure your prescribing physician is in-network with UnitedHealthcare. Out-of-network providers face additional hurdles and may require different forms or processes.

What You Need to Gather

Essential Clinical Documentation

Diagnosis Confirmation:

  • ICD-10 codes: B44.0 (invasive pulmonary aspergillosis) or B46.x (mucormycosis subtypes)
  • Culture results showing fungal growth
  • Pathology reports (if tissue biopsy performed)
  • Imaging studies (CT or MRI showing characteristic findings)
  • Laboratory markers (galactomannan, beta-D-glucan, or PCR testing)

Previous Therapy Documentation:

  • Records of voriconazole trial and outcome (for aspergillosis cases)
  • Documentation of adverse reactions, contraindications, or treatment failures
  • Amphotericin B trial documentation (for mucormycosis cases)
  • Drug interaction concerns with current medications

Specialist Involvement:

  • Infectious disease consultation notes
  • Treatment plan with specific dosing and monitoring parameters
  • Clinical rationale for choosing Cresemba over alternatives

Administrative Requirements

  • Current UnitedHealthcare member ID card
  • Prescriber NPI and DEA numbers
  • Patient demographics and contact information
  • Prior authorization request form (available through provider portal)
From our advocates: "We've seen the biggest difference when providers include a clear timeline of previous antifungal treatments and their outcomes. A simple table showing 'Drug X tried from Date A to Date B, discontinued due to liver toxicity' makes the medical necessity crystal clear to reviewers. This level of detail often prevents the back-and-forth requests for additional information."

How to Submit Your Request

Primary Submission Method: Provider Portal

  1. Log into the UnitedHealthcare Provider Portal
  2. Navigate to "Prior Authorization & Notification"
  3. Search for "Cresemba" or "isavuconazole"
  4. Complete the electronic form with all required fields
  5. Upload supporting documentation as PDF files
  6. Submit and save your confirmation number

Alternative: Fax Submission

If portal access isn't available, fax completed forms to 1-844-403-1027 for commercial plans. Include:

  • Completed prior authorization form
  • All supporting clinical documentation
  • Cover sheet with patient information and provider contact details

Specialty Pharmacy Coordination

Since Cresemba must be dispensed through specialty pharmacies, typically OptumRx for UnitedHealthcare members, coordinate with the pharmacy early in the process. They can often assist with prior authorization submissions and patient enrollment.

Following Up on Your Request

When to Follow Up

  • Day 3-5: Check portal for status updates or requests for additional information
  • Day 7-10: Call if no response received (standard processing time)
  • Day 3: For urgent/expedited requests

What to Ask When Calling

"I'm calling to check on prior authorization request #[your reference number] for Cresemba for patient [name]. Can you tell me the current status and if any additional information is needed?"

Contact Information

  • OptumRx PA hotline: 1-800-711-4555
  • UnitedHealthcare provider services: Number on your provider ID card
  • Member services: Number on patient's insurance card

Understanding Timelines

Request Type UnitedHealthcare Response Time Ohio Requirements
Standard PA 5-15 business days Must respond within reasonable time
Urgent/Expedited 72 hours Required for life-threatening conditions
Appeal (First Level) 5-10 business days Must allow 21 days to file
External Review 30 days (standard) 72 hours (expedited)

If More Information is Requested

Common requests include:

  • Additional lab results: Recent fungal cultures or susceptibility testing
  • Clearer contraindication documentation: Specific reasons why voriconazole cannot be used
  • Specialist consultation: More detailed infectious disease notes
  • Treatment timeline: Clearer documentation of previous therapy attempts

Respond promptly to these requests—delays can restart the review timeline. Counterforce Health specializes in helping providers craft comprehensive responses that address payer concerns while highlighting the medical necessity for specialty medications like Cresemba.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution
"Step therapy not met" Document voriconazole contraindication or failure
"Not medically necessary" Strengthen clinical documentation with specialist notes
"Missing information" Resubmit with complete diagnostic workup
"Non-formulary" Request formulary exception with clinical justification

Ohio Appeal Process

Internal Appeals (Required First Step):

  • First level: File within 21 days of denial
  • Second level: Available if first level unsuccessful
  • Submit via provider portal or fax with additional supporting evidence

External Review (After Internal Appeals):

  • File within 180 days of final internal denial
  • Handled by Ohio Department of Insurance
  • Decision timeline: 30 days standard, 72 hours expedited
  • Decision is binding on UnitedHealthcare

Ohio Department of Insurance Contact:

  • Phone: 1-800-686-1526
  • Website: insurance.ohio.gov
  • External review forms available online

When to Request Expedited Review

Ohio law allows expedited external review when delay would:

  • Seriously jeopardize the patient's life or health
  • Risk loss of function or ability to regain function
  • Cause severe pain that cannot be managed without the requested treatment

Renewal and Reauthorization

Cresemba prior authorizations typically approve for 90 days initially. For renewal:

What to Include

  • Treatment response documentation: Clinical improvement, lab results, imaging
  • Continued medical necessity: Ongoing infection or need for suppressive therapy
  • Updated specialist notes: Current treatment plan and monitoring results
  • Susceptibility testing: If available, to confirm isavuconazole effectiveness

Timing

Submit renewal requests 2-3 weeks before current authorization expires to prevent treatment interruptions.

Quick Reference Checklist

Before Starting:

  • Confirm UnitedHealthcare plan type and formulary tier
  • Verify in-network provider status
  • Check specialty pharmacy requirements

Documentation to Gather:

  • ICD-10 diagnosis codes (B44.0 or B46.x)
  • Culture/pathology results
  • Imaging studies (CT/MRI)
  • Previous antifungal therapy records
  • Infectious disease consultation notes
  • Contraindication documentation

Submission:

  • Complete prior authorization via provider portal
  • Upload all supporting documents
  • Save confirmation/reference number
  • Coordinate with specialty pharmacy

Follow-up:

  • Check status after 3-5 days
  • Respond promptly to information requests
  • Calendar renewal date (usually 90 days)

FAQ

How long does UnitedHealthcare PA take in Ohio? Standard requests take 5-15 business days. Urgent requests must be processed within 72 hours if the delay would jeopardize patient health.

What if Cresemba is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate or ineffective.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Provide physician documentation of urgency when filing the appeal.

Does step therapy apply if I failed voriconazole outside Ohio? Yes, prior therapy documentation from any location counts toward meeting step therapy requirements, as long as it's properly documented.

What's the difference between internal and external appeals? Internal appeals are reviewed by UnitedHealthcare staff. External appeals in Ohio are reviewed by independent medical experts through the Ohio Department of Insurance and are binding on the insurer.

How much will Cresemba cost with UnitedHealthcare coverage? Costs vary by plan type and tier placement. Specialty medications typically have higher copayments or coinsurance. Contact member services for your specific cost-sharing details.

Can my doctor request a peer-to-peer review? Yes, physicians can request to speak directly with UnitedHealthcare's medical director to discuss complex cases and provide additional clinical context.

What if I need Cresemba for off-label use? Off-label uses face additional scrutiny and may require extensive literature support and specialist documentation. Consider working with coverage specialists who understand payer requirements for off-label indications.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements for medications like Cresemba. Our platform analyzes denial letters and payer policies to create targeted, evidence-backed appeals that align with each plan's specific requirements. By understanding exactly what UnitedHealthcare needs to see for Cresemba approvals, we help reduce the back-and-forth that delays patient access to critical treatments. Learn more about our services at www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not replace professional medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions. For personalized assistance with Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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