By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by UnitedHealthcare in North Carolina: Complete Prior Authorization Guide

Answer Box: Getting Cresemba Covered by UnitedHealthcare in North Carolina

UnitedHealthcare requires prior authorization for Cresemba (isavuconazole) in North Carolina through OptumRx. You'll need: confirmed invasive aspergillosis (B44.0) or mucormycosis (B46.x) diagnosis, documentation that voriconazole failed/can't be used, and infectious disease specialist consultation. Submit via the UnitedHealthcare Provider Portal with complete clinical records. If denied, appeal internally first, then use North Carolina's Smart NC external review program at 855-408-1212. Start the PA process early—approval can take 5-15 business days.

Table of Contents

  1. Verify Your Plan Coverage
  2. Prior Authorization Requirements
  3. Forms and Submission Portals
  4. OptumRx Specialty Pharmacy Enrollment
  5. Common Denial Reasons and Solutions
  6. Appeals Process: Internal and External
  7. Support Contacts and Resources
  8. FAQ: Cresemba Coverage in North Carolina

Verify Your Plan Coverage

Before starting the prior authorization process, confirm your UnitedHealthcare plan covers Cresemba and identify any specific requirements for North Carolina members.

Coverage Verification Steps

  1. Check your member portal at myuhc.com or call the number on your insurance card
  2. Verify formulary status - Cresemba is typically a Tier 4 specialty medication requiring prior authorization
  3. Confirm OptumRx is your pharmacy benefit manager - most UnitedHealthcare plans in North Carolina use OptumRx for specialty medications
  4. Review your plan's medical policy for isavuconazole coverage criteria
Note: Self-funded employer plans may have different requirements than standard UnitedHealthcare commercial plans.

Prior Authorization Requirements

UnitedHealthcare requires comprehensive clinical documentation to approve Cresemba for invasive fungal infections.

Essential Clinical Criteria

Requirement Documentation Needed ICD-10 Code
Invasive Aspergillosis Culture, pathology, or imaging evidence B44.0
Mucormycosis Tissue biopsy, culture, or specialist attestation B46.x
Voriconazole Step Therapy Failed, intolerant, or contraindicated Document reason
Specialist Involvement Infectious disease consultation required Include notes

Medical Necessity Documentation

Your healthcare provider must submit:

  • Laboratory evidence: Positive cultures, galactomannan, or beta-D-glucan
  • Imaging studies: CT or MRI showing invasive fungal disease
  • Previous antifungal therapy: Detailed history of voriconazole use/failure
  • Risk factors: Immunosuppression, transplant status, neutropenia
  • Treatment plan: Dosing, duration, and monitoring parameters

Forms and Submission Portals

UnitedHealthcare Provider Portal Submission

The fastest way to submit prior authorization requests is through the UnitedHealthcare Provider Portal:

  1. Login with your One Healthcare ID
  2. Select "Prior Authorization and Notification"
  3. Upload all supporting medical records
  4. Track your request status in real-time

Alternative Submission Methods

  • Fax: 1-844-403-1027 (commercial plans) or 1-866-940-7328 (Medicaid plans)
  • Phone: 1-800-711-4555 for urgent requests
  • CoverMyMeds: Electronic submission for participating providers
Tip: Always use the most current PA forms from the UnitedHealthcare provider website. Outdated forms may delay processing.

Required Forms Checklist

  • UnitedHealthcare Prior Authorization Request Form
  • Clinical notes from infectious disease specialist
  • Laboratory and imaging reports
  • Previous treatment history documentation
  • Patient consent for specialty pharmacy transfer

OptumRx Specialty Pharmacy Enrollment

Once prior authorization is approved, Cresemba must be dispensed through OptumRx specialty pharmacy for most UnitedHealthcare plans in North Carolina.

Enrollment Process

  1. Provider submits approved prescription to OptumRx
  2. OptumRx contacts patient for enrollment
  3. Patient provides insurance and shipping information
  4. Medication ships directly to patient's home

Transfer from Retail Pharmacy

If you already have a Cresemba prescription at a retail pharmacy:

  • Contact OptumRx at the number on your insurance card
  • Provide prescription details and retail pharmacy information
  • OptumRx coordinates the transfer process
  • First shipment typically arrives within 2-3 business days

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document voriconazole failure/contraindication Treatment history, adverse events
Lack of specialist involvement Obtain ID consultation Specialist evaluation notes
Insufficient diagnostic evidence Provide additional lab/imaging Culture results, pathology reports
Off-label use Submit medical literature support Peer-reviewed studies, guidelines

Medical Necessity Letter Template

When appealing a denial, your provider should include:

  • Clinical presentation: Specific symptoms and risk factors
  • Diagnostic evidence: Lab results and imaging findings
  • Treatment rationale: Why Cresemba is medically necessary
  • Guideline support: References to infectious disease guidelines
  • Monitoring plan: Safety and efficacy assessments

Appeals Process: Internal and External

Internal Appeals with UnitedHealthcare

If your prior authorization is denied, you have 180 days to file an internal appeal:

  1. Submit reconsideration via provider portal or fax
  2. Include additional documentation addressing denial reasons
  3. Request peer-to-peer review with medical director
  4. Track appeal status through provider portal

North Carolina External Review

After exhausting internal appeals, North Carolina residents can request an independent external review through Smart NC.

Smart NC External Review Process

  • Contact: 855-408-1212 (toll-free)
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to consumers
  • Eligibility: State-regulated plans (not self-funded employer plans)

Required Documents for External Review

  • Final internal appeal denial letter
  • Original prior authorization request
  • All supporting medical records
  • Smart NC Request for Assistance form
From our advocates: We've seen cases where patients received approval on external review after providing additional peer-reviewed literature supporting off-label Cresemba use for refractory aspergillosis. The key was demonstrating that standard therapies had failed and Cresemba represented the best available treatment option based on published evidence.

Support Contacts and Resources

UnitedHealthcare Contact Information

  • Provider Services: 1-888-842-4233
  • Member Services: Number on insurance card
  • Prior Authorization Status: Provider portal or 1-800-711-4555

Cresemba Support Program

Astellas Pharma Support Solutions offers:

  • Benefit verification assistance
  • Prior authorization support
  • Copay assistance programs (for eligible patients)
  • Clinical education resources

North Carolina Consumer Assistance

  • Smart NC: 855-408-1212
  • NC Department of Insurance: ncdoi.gov
  • Consumer complaint portal: Available on NCDOI website

When Coverage Gets Complex: Counterforce Health Can Help

Navigating prior authorization denials and appeals can be overwhelming, especially for complex specialty medications like Cresemba. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each payer's requirements.

For medications like Cresemba, Counterforce Health pulls the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and dosing rationale. The system produces letters that meet UnitedHealthcare's procedural requirements while tracking deadlines and required documentation.

FAQ: Cresemba Coverage in North Carolina

How long does UnitedHealthcare prior authorization take in North Carolina? Standard PA requests typically take 5-15 business days. Urgent requests can be processed within 72 hours if clinical urgency is documented.

What if Cresemba is not on my plan's formulary? You can request a formulary exception with strong clinical justification. Include peer-reviewed literature and specialist support for your request.

Can I get a temporary supply while waiting for approval? UnitedHealthcare may provide a temporary supply during the first 90 days of membership or during the appeals process for continuing therapy.

Does step therapy apply if I failed voriconazole outside North Carolina? Yes, document the failure regardless of where it occurred. Include complete treatment records and adverse event documentation.

What happens if my internal appeal is denied? You can request external review through Smart NC within 120 days of the final internal denial. This is an independent review at no cost to you.

Can my doctor request a peer-to-peer review? Yes, providers can request to speak directly with UnitedHealthcare's medical director to discuss the clinical rationale for Cresemba.

Are there patient assistance programs for Cresemba? Astellas offers copay assistance and patient support programs. Contact Cresemba Support Solutions for eligibility information.

How do I know if my employer plan follows North Carolina regulations? Self-funded employer plans may not be subject to state regulations. Check with your HR department or contact Smart NC to verify eligibility for external review.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage options. Coverage policies may vary by plan and are subject to change. For the most current information, contact UnitedHealthcare directly or visit their provider website.

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