By Counterforce Health Team in Dupixent (dupilumab) —

How to Get Dupixent (dupilumab) Covered by UnitedHealthcare in Georgia: Complete Coding, Appeals, and Cost Guide

Quick Answer: Getting Dupixent Covered by UnitedHealthcare in Georgia

UnitedHealthcare requires prior authorization for Dupixent (dupilumab) with strict step therapy and documentation requirements. The fastest path to approval: ensure your doctor submits complete medical records showing failed conventional therapies, correct ICD-10 diagnosis codes, and recent lab values through the OptumRx provider portal. If denied, you have 180 days to appeal internally and 60 days for Georgia external review. Start by calling UnitedHealthcare member services at the number on your card to verify coverage and requirements.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Dupixent Indications
  3. Product Coding: HCPCS, NDC, and Billing
  4. Clean Prior Authorization Anatomy
  5. Frequent Pitfalls to Avoid
  6. UnitedHealthcare Verification Steps
  7. Appeals Process in Georgia
  8. Cost-Saving Options
  9. Pre-Submission Checklist

Coding Basics: Medical vs. Pharmacy Benefit

UnitedHealthcare typically processes Dupixent under the pharmacy benefit through OptumRx as a self-administered specialty drug. This means:

  • Pharmacy Benefit: NDC-based billing through specialty pharmacy (most common)
  • Medical Benefit: HCPCS/J-code billing for office administration (limited scenarios)
Note: UnitedHealthcare maintains a Self-Administered Medications List that includes Dupixent, signaling pharmacy benefit processing is preferred.

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all indications OptumRx provider portal UHC PA Policy
Formulary Tier Specialty (Tier 4-5) Member portal/formulary Plan-specific formulary
Step Therapy Yes, varies by indication PA policy document UHC PA requirements
Quantity Limits Per indication dosing PA approval letter FDA labeling
Site of Care Home/office (specialty pharmacy) Plan benefits Member handbook

ICD-10 Mapping for Dupixent Indications

Accurate diagnosis coding is critical for Dupixent approval. Use the most specific code available:

Primary Indications and ICD-10 Codes

Atopic Dermatitis

  • L20.0 - Besnier's prurigo (infantile eczema)
  • L20.8 - Other atopic dermatitis
  • L20.9 - Atopic dermatitis, unspecified

Asthma

  • J45.0 - Predominantly allergic asthma
  • J45.1 - Nonallergic asthma
  • J45.9 - Asthma, unspecified
  • J45.902 - Unspecified asthma with acute exacerbation

Chronic Rhinosinusitis with Nasal Polyps

  • J32.9 - Chronic sinusitis, unspecified
  • J33.0 - Polyp of nasal cavity
  • J33.9 - Nasal polyp, unspecified

Eosinophilic Esophagitis

  • K20.1 - Eosinophilic esophagitis

Documentation Requirements

Your medical record must include:

  • Specific diagnosis with supporting clinical findings
  • Disease severity measures (EASI scores for AD, spirometry for asthma)
  • Treatment history with dates, medications, and outcomes
  • Recent lab values (eosinophil counts where applicable)

Product Coding: HCPCS, NDC, and Billing

NDC Numbers for Dupixent

  • 0024-5911-02 (300mg/2mL prefilled syringe, 2-pack)
  • 0024-5910-02 (200mg/1.14mL prefilled syringe, 2-pack)
  • 0024-5912-02 (300mg/2mL prefilled pen, 2-pack)

HCPCS Coding (Medical Benefit)

When billed under medical benefit:

  • J3590 - Unclassified biologics (temporary code)
  • Include NDC number and units on claim
  • Document administration method and site
Tip: Most UnitedHealthcare plans prefer pharmacy benefit processing. Verify benefit channel before ordering.

Clean Prior Authorization Anatomy

A successful Dupixent PA submission includes:

Required Documentation

  1. Completed PA form with all fields
  2. Medical records showing diagnosis and severity
  3. Treatment history with specific dates and outcomes
  4. Lab results (eosinophil counts, TB screening)
  5. Letter of medical necessity from specialist

Step Therapy Requirements by Indication

Atopic Dermatitis

  • Failed medium-to-high potency topical corticosteroids
  • Failed topical calcineurin inhibitors or crisaborole
  • Documented inadequate response or intolerance

Asthma

  • High-dose inhaled corticosteroid plus LABA
  • Eosinophilic phenotype (≥150 cells/μL) or oral steroid dependence
  • At least 2 exacerbations requiring systemic steroids per year

Chronic Rhinosinusitis with Nasal Polyps

  • Failed intranasal corticosteroids
  • Prior systemic corticosteroids or sinus surgery
  • Persistent symptoms with polyp disease

Frequent Pitfalls to Avoid

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Step therapy not met Document all failed therapies Dates, drugs, outcomes, adverse effects
Missing eosinophil count Recent lab within 3-6 months CBC with differential
No TB screening Negative test within 12 months PPD or IGRA results
Insufficient medical necessity Severity scores and impact EASI, ACT, quality of life measures
Wrong diagnosis code Use most specific ICD-10 Clinical documentation supporting code

Documentation Mistakes to Avoid

  • Using unspecified ICD-10 codes when specific ones apply
  • Missing dates for prior therapy trials
  • Incomplete adverse event documentation
  • Outdated lab values or screening tests

UnitedHealthcare Verification Steps

Before submitting your PA:

  1. Check formulary status via member portal or pharmacy benefits line
  2. Verify PA requirements using current policy documents
  3. Confirm specialist requirements (dermatology, allergy, pulmonology)
  4. Review quantity limits and dosing restrictions
  5. Check site-of-care requirements (home vs. office administration)

Key UnitedHealthcare Resources

Appeals Process in Georgia

Internal Appeal Timeline

  • Deadline: 180 days from denial date
  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases
  • Required documents: Denial letter, medical records, prescriber letter

Georgia External Review

After internal appeal failure:

  • Deadline: 60 days from final internal denial
  • Process: Submit application to Georgia Department of Insurance
  • Timeline: 30-45 days for standard review, 72 hours for expedited
  • Cost: Free for consumers
  • Contact: Georgia DOI Consumer Services at 1-800-656-2298
From our advocates: "We've seen many Georgia patients successfully overturn Dupixent denials by including detailed treatment timelines and severity scores in their appeals. The key is showing clear medical necessity and why alternatives failed or are inappropriate."

Required Appeal Documents

  • Original denial letter from UnitedHealthcare
  • All medical records used in PA
  • Prescriber's detailed letter of medical necessity
  • Supporting literature and guidelines
  • Updated lab values or clinical assessments

Cost-Saving Options

Manufacturer Support

  • Dupixent MyWay: Copay assistance up to $13,000/year for eligible patients
  • Bridge Program: Free drug during appeals process
  • Eligibility: Commercial insurance required, income restrictions may apply
  • Website: dupixent.com/support-savings

Additional Resources

  • Patient Access Network Foundation grants
  • HealthWell Foundation assistance
  • State pharmaceutical assistance programs
  • Specialty pharmacy financial counseling

Pre-Submission Checklist

Before submitting your Dupixent PA:

Clinical Documentation

  • Confirmed diagnosis with ICD-10 code
  • Disease severity scores documented
  • Complete treatment history with dates
  • Recent lab values (eosinophils, TB screening)
  • Specialist evaluation and recommendation

Administrative Requirements

  • Current PA form completed
  • All required signatures obtained
  • Supporting literature attached
  • Submission method confirmed (portal vs. fax)
  • Follow-up plan established

Appeal Preparation

  • Calendar internal appeal deadline (180 days)
  • Note Georgia external review deadline (60 days)
  • Gather additional supporting documentation
  • Identify prescriber availability for peer-to-peer

Getting specialized help with insurance approvals can make a significant difference in your outcome. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals with the right clinical evidence and procedural requirements for your specific situation.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Georgia? Standard PA decisions typically take 7-14 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Dupixent is non-formulary on my plan? You can request a formulary exception with medical necessity documentation showing why preferred alternatives are inappropriate.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Your doctor must document the urgent medical need.

Does step therapy apply if I failed therapies outside Georgia? Yes, documented treatment failures from any location count toward step therapy requirements if properly documented.

What happens if I miss the appeal deadline? Contact UnitedHealthcare immediately to request late filing consideration. Some circumstances may allow deadline extensions.

Who can prescribe Dupixent for UnitedHealthcare coverage? Typically requires specialists: dermatologists for AD, allergists/pulmonologists for asthma, ENT for nasal polyps, gastroenterologists for EoE.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and does not guarantee coverage approval. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. Coverage policies vary by plan and may change over time. For personalized assistance with your appeal, consider working with Counterforce Health or other qualified patient advocacy services.

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