By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by UnitedHealthcare in Washington: Prior Authorization Guide

Answer Box: Quick Path to Cresemba Coverage

UnitedHealthcare requires prior authorization for Cresemba (isavuconazole) in Washington. Your fastest path: (1) Confirm diagnosis codes B44.0 (invasive aspergillosis) or B46.x (mucormycosis), (2) Document any voriconazole contraindications or failures, and (3) Submit PA request via UnitedHealthcare Provider Portal within 180 days. OptumRx handles specialty pharmacy dispensing. If denied, you have strong appeal rights in Washington including independent external review through certified IROs.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Washington
  7. If You're Asked for More Information
  8. If Your Request is Denied
  9. Renewal and Re-authorization
  10. Appeals Process in Washington
  11. Costs and Patient Support
  12. FAQ

What This Guide Covers

This guide helps Washington residents get Cresemba (isavuconazole) covered by UnitedHealthcare when treating invasive aspergillosis or mucormycosis. Cresemba is a specialty antifungal that costs approximately $1,620 per 14-capsule bottle at wholesale, making insurance approval essential for most patients.

Who this helps:

  • Patients diagnosed with invasive fungal infections
  • Clinicians submitting prior authorization requests
  • Caregivers navigating the appeals process

Cresemba treats serious fungal infections including invasive aspergillosis and mucormycosis in adults and select pediatric patients. It's often preferred when voriconazole can't be used due to drug interactions, liver toxicity, or hypersensitivity reactions.

Before You Start: Verify Your Coverage

Check Your Plan Type

Commercial plans: Most require prior authorization through OptumRx Medicare Advantage: Subject to UnitedHealthcare's Medicare formulary rules Medicaid (Apple Health): Different PA requirements may apply

Tip: Call the member services number on your insurance card to confirm Cresemba's formulary status and any step therapy requirements.

Confirm Network Status

Cresemba is designated as a specialty medication by UnitedHealthcare and must be dispensed through approved specialty pharmacies, typically OptumRx. Verify your specialty pharmacy network before starting the PA process.

Gather What You Need

Essential Documentation Checklist

Clinical Information:

  • Confirmed diagnosis with appropriate ICD-10 codes:
    • B44.0: Invasive pulmonary aspergillosis
    • B46.0-B46.9: Various forms of mucormycosis
  • Culture results, pathology reports, or biomarker evidence
  • Imaging studies (CT, MRI) showing infection
  • Risk factors (immunosuppression, diabetes, steroid use)

Prior Therapy Documentation:

  • Previous antifungal treatments and outcomes
  • Documented contraindications to voriconazole:
    • Drug interactions with CYP3A4 substrates
    • Hepatotoxicity or liver function abnormalities
    • Hypersensitivity reactions
    • QTc prolongation concerns

Provider Information:

  • Infectious disease specialist consultation (often required)
  • Treatment plan and duration
  • Monitoring parameters
Note: UnitedHealthcare commonly requires medical rationale for why voriconazole cannot be used, as it's typically considered first-line therapy.

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Access the Portal

2. Complete Required Fields

  • Patient demographics and insurance information
  • Diagnosis codes (B44.0 or B46.x)
  • Prescriber information and specialty
  • Requested quantity and duration

3. Upload Supporting Documents

  • Clinical notes from infectious disease specialist
  • Culture/pathology results
  • Prior therapy documentation
  • Contraindication evidence for alternatives

4. Submit and Track

  • Record confirmation number
  • Note submission date for timeline tracking
  • Set follow-up reminders

Alternative Submission Methods

Phone: OptumRx prior authorization line (number on provider portal) Fax: Check current fax number on denial letters or portal

Follow-Up and Tracking

Day 3: Confirm receipt of submission Day 5-7: Check for additional information requests Day 10-14: Follow up if no determination received

Sample Call Script

"Hello, I'm calling to check the status of prior authorization request [confirmation number] for patient [name] submitted on [date]. The request is for Cresemba for invasive aspergillosis. Can you provide a status update and expected determination date?"

Typical Timelines in Washington

Standard Review Times

Non-urgent requests: Up to 15 business days Urgent requests: 72 hours for commercial plans, 24 hours for Medicare Additional information requests: Clock resets when documents submitted

Washington State Protection: If OptumRx doesn't respond within required timeframes, exception requests are automatically granted per state regulations.

If You're Asked for More Information

Common Information Requests

Medical Necessity Questions:

  • Specific infection site and severity
  • Why Cresemba vs. other antifungals
  • Expected treatment duration
  • Monitoring plan

Documentation to Provide:

  • Peer-reviewed literature supporting use
  • Professional society guidelines
  • FDA prescribing information
  • Specialist consultation notes

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Step therapy not met Document voriconazole contraindication Allergy history, drug interactions, liver function tests
Not medically necessary Provide specialist consultation ID specialist notes, culture results, severity indicators
Missing information Submit complete clinical picture All diagnostic tests, prior treatments, risk factors

Immediate Next Steps

  1. Review denial letter carefully - note specific reasons and required evidence
  2. Contact prescriber - ensure all clinical rationale is documented
  3. Prepare appeal - gather additional supporting evidence
  4. Consider peer-to-peer review - request direct physician discussion

Appeals Process in Washington

Washington provides strong consumer protections for insurance appeals, making it one of the most favorable states for overturning denials.

Internal Appeals (First Level)

Timeline: Must file within 180 days of denial notice Process: Submit written appeal with additional documentation Response time: 30 days for standard appeals, 72 hours for urgent

External Review (Independent Review Organization)

Eligibility: Available after internal appeal denial Timeline: Request within 120 days of final internal denial Process: Washington-certified IRO reviews case independently Decision: Binding on UnitedHealthcare if overturned

Washington Advantage: The state's Office of the Insurance Commissioner maintains a registry of qualified medical experts who often serve as IRO reviewers, including specialists familiar with rare fungal infections.

Getting Help

Washington State Office of the Insurance Commissioner

Renewal and Re-authorization

Planning Ahead

Calendar reminders: Set alerts 30 days before current authorization expires Updated documentation: Gather recent labs, imaging, and clinical notes Treatment response: Document infection improvement or ongoing need

Evidence for Renewal

  • Current culture results or biomarkers
  • Response to therapy documentation
  • Continued medical necessity
  • Any complications or treatment modifications

Costs and Patient Support

Financial Assistance Options

Astellas Patient Support: Cresemba support program offers copay assistance and prior authorization help

Foundation Support: Patient Access Network Foundation and other organizations may provide grants for antifungal therapy

State Programs: Washington Apple Health (Medicaid) expansion provides coverage for eligible residents

FAQ

Q: How long does UnitedHealthcare prior authorization take in Washington? A: Standard requests: up to 15 business days. Urgent requests: 72 hours for commercial plans, 24 hours for Medicare.

Q: What if Cresemba is non-formulary on my plan? A: You can request a formulary exception with strong clinical documentation. Non-formulary doesn't mean automatic denial.

Q: Can I request an expedited appeal? A: Yes, if your condition could be seriously jeopardized by delays. Washington requires 72-hour responses for urgent appeals.

Q: Does step therapy apply if I've failed voriconazole outside Washington? A: Prior therapy documentation from any location is typically accepted. Provide complete records of previous treatments.

Q: What happens if OptumRx delays my specialty pharmacy shipment? A: Contact UnitedHealthcare member services immediately. Washington has patient protection rules for specialty medication access.

Q: Can my regular pharmacy fill Cresemba? A: No, UnitedHealthcare requires specialty pharmacy dispensing through OptumRx or approved network pharmacies.

Counterforce Health: Streamlining Your Appeal Process

When facing complex prior authorization denials, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and payer policies, then drafts point-by-point rebuttals using the right clinical evidence and regulatory citations. For medications like Cresemba, this includes pulling FDA labeling, specialty guidelines, and peer-reviewed studies that support medical necessity arguments.

This guide provides general information and should not replace professional medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For additional help with Washington insurance appeals, contact the Office of the Insurance Commissioner at 1-800-562-6900.

Sources & Further Reading

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