By Counterforce Health Team in Emgality (galcanezumab-gnlm) —

How to Get Emgality Approved by UnitedHealthcare in Illinois: Complete Prior Authorization Guide (2025)

Quick Answer: To get Emgality (galcanezumab) covered by UnitedHealthcare in Illinois, you'll need prior authorization through OptumRx showing you've failed at least two preventive medications (like topiramate or propranolol) and have 4+ migraine days monthly. Submit requests via the UnitedHealthcare Provider Portal or call 1-800-711-4555. If denied, you have 21 days for internal appeal and 30 days for Illinois external review. Start by gathering your headache diary and prior medication records today.

Table of Contents

What This Guide Covers

This comprehensive guide helps Illinois residents navigate UnitedHealthcare's prior authorization process for Emgality (galcanezumab-gnlm), a monthly injectable medication for migraine prevention and episodic cluster headache treatment. Whether you're a patient working with your doctor or a clinician submitting requests, you'll find step-by-step instructions, required documentation, appeal procedures, and Illinois-specific timelines.

Emgality costs approximately $741.69 per 120-mg pen at list price, making prior authorization essential for most patients. With proper documentation, approval rates are favorable—UnitedHealthcare's Medicare Advantage PA denial rate averages around 9%, and successful appeals overturn roughly 82% of denials for CGRP medications like Emgality.

Before You Start: Verify Your Coverage

Check Your Plan Type and Pharmacy Benefits

First, confirm whether your UnitedHealthcare plan includes prescription drug coverage through OptumRx. As of January 1, 2025, OptumRx manages prior authorization for UnitedHealthcare plans using UnitedHealthcare clinical criteria.

Verify Network Status

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

Confirm Formulary Status

Check your plan's 2025 Prescription Drug List to see Emgality's formulary tier and any step therapy requirements. Look for "ST" notation, which indicates step therapy is required before coverage approval.

Gather What You Need

Essential Documentation Checklist

Patient Information:

  • UnitedHealthcare member ID and policy details
  • Complete contact information and date of birth
  • Current prescribing physician's NPI and contact details

Medical Records:

  • Diagnosis documentation with ICD-10 codes (G43.709 for chronic migraine, G44.009 for cluster headache)
  • Headache diary showing at least 4 migraine days per month for 3+ months
  • Documentation of functional impact on daily activities
  • Recent neurological examination notes

Prior Treatment History:

  • Records of at least two failed preventive medications from different classes
  • Specific medications tried (doses, duration, outcomes)
  • Reasons for discontinuation (inadequate response, side effects, contraindications)
  • Documentation of contraindications to standard preventives if applicable

Supporting Clinical Evidence:

  • Recent lab results or imaging ruling out secondary causes
  • Emergency department visits for severe migraines
  • Previous neurology consultation notes
  • Any relevant comorbidities affecting treatment choices
Tip: Start documenting your headache frequency and severity at least 3 months before requesting Emgality. This creates a stronger case for medical necessity.

Submit Your Prior Authorization Request

Primary Submission Methods

Online Portal (Recommended):

Phone Submission:

  • Call 1-800-711-4555 for urgent requests
  • Have all documentation ready before calling
  • Request expedited review if clinically appropriate

Illinois-Specific Option: Providers may use the Illinois Uniform Electronic Prior Authorization Form designed specifically for prescription drug prior authorization requests with commercial health insurance issuers.

Step Therapy Requirements

Most UnitedHealthcare plans require trial and failure of at least two preventive medications before approving Emgality. Common required trials include:

Medication Class Examples Typical Trial Duration
Beta Blockers Propranolol, metoprolol 2+ months at therapeutic dose
Anticonvulsants Topiramate, valproic acid 2+ months at therapeutic dose
Tricyclic Antidepressants Amitriptyline, nortriptyline 2+ months at therapeutic dose
Calcium Channel Blockers Verapamil 2+ months at therapeutic dose

Medical Necessity Letter Components

Your healthcare provider should include these elements in the prior authorization request:

Essential Clinical Information:

  • Clear documentation of migraine frequency (4+ days per month)
  • Detailed functional impact assessment
  • Comprehensive medication history with specific failure reasons
  • Contraindications to alternative treatments
  • Treatment goals and expected outcomes

Supporting Evidence:

  • References to FDA labeling for approved indications
  • Relevant clinical guidelines (American Headache Society, American Academy of Neurology)
  • Peer-reviewed studies supporting efficacy in similar patient populations

Follow-Up and Tracking

Monitoring Your Request Status

Check your prior authorization status regularly through the UnitedHealthcare Provider Portal. Log in to UHCprovider.com and navigate to the Prior Authorizations section for real-time updates.

Sample Follow-Up Call Script

"Hello, I'm calling to check on the status of a prior authorization request for Emgality (galcanezumab) for patient [name], member ID [number]. The request was submitted on [date]. Can you provide the current status and any additional information needed?"

Document everything: Keep records of reference numbers, representative names, and any additional requirements mentioned during calls.

When to Follow Up

  • Day 3-5: Initial status check
  • Day 10: If no decision, escalate to supervisor
  • Day 15: Consider peer-to-peer review if still pending

Typical Timelines in Illinois

Standard Processing Times

Pre-service Requests:

  • Standard review: Up to 15 business days
  • Expedited review: 24-72 hours for urgent cases
  • Appeals: 21 calendar days to file after denial

Illinois-Specific Timelines:

  • Internal appeals must be decided within 15 business days for pre-service requests
  • Expedited internal appeals: 24 hours
  • External review requests must be filed within 30 days of final denial (stricter than many states)
  • External review decisions: 5 business days after IRO receives all materials
Note: Illinois has a shorter external review filing window (30 days) compared to the 4-month window in many states. Act promptly after appeal denials.

If You Need to Provide More Information

Common Additional Information Requests

Clinical Clarifications:

  • More detailed headache diary with specific triggers and symptoms
  • Additional documentation of prior medication trials
  • Clarification of contraindications to alternative treatments
  • Updated functional assessment scores

Administrative Requirements:

  • Corrected member information
  • Updated prescriber credentials
  • Additional ICD-10 codes for comorbidities

Responding Effectively

Submit additional information promptly through the same channel used for the original request. Include your original reference number and clearly label all supplemental documentation.

If Your Request Is Denied

Understanding Denial Reasons

Common denial codes and their meanings:

Denial Reason What It Means How to Address
Step therapy not met Insufficient preventive medication trials Document additional failed treatments or contraindications
Medical necessity not established Inadequate clinical documentation Provide detailed headache diary and functional impact assessment
Non-formulary medication Emgality not on preferred drug list Request formulary exception with clinical rationale
Quantity limits exceeded Requesting more than plan allows Justify medical need for higher quantity

Internal Appeal Process

UnitedHealthcare follows a 2-step appeals process. You have 21 calendar days from the denial date to file an internal appeal for pre-service requests.

Appeal Submission Options:

  • Electronic submission through UnitedHealthcare Provider Portal (required starting August 2025)
  • Written appeal with supporting documentation
  • Request peer-to-peer review with medical director within 24 hours of denial

Peer-to-Peer Review Strategy

Request a peer-to-peer discussion with a UnitedHealthcare medical director before filing a formal appeal. This allows your physician to present additional clinical context and may result in approval without lengthy appeal processes.

Preparation Tips:

  • Have all clinical documentation readily available
  • Prepare talking points about why Emgality is medically necessary
  • Be ready to discuss specific contraindications to alternative treatments

External Review in Illinois

If internal appeals fail, Illinois residents can request independent external review through the Illinois Department of Insurance. This process involves an Independent Review Organization (IRO) with expertise in your condition.

Illinois External Review Process:

  • File within 30 days of final internal appeal denial
  • No cost to consumers (insurers pay IRO fees)
  • Decision binding on insurance company
  • Standard review: ~30 days total
  • Expedited review: 24-72 hours for urgent cases

Illinois Department of Insurance Resources:

Renewal and Re-Authorization

Planning for Renewal

Most prior authorizations for Emgality require annual renewal. Calendar your renewal request 60-90 days before expiration to avoid treatment interruption.

Renewal Documentation

Required for Renewal:

  • Updated headache diary showing continued need
  • Treatment response documentation
  • Any new contraindications to alternative treatments
  • Continued medical necessity justification

Strengthening Your Renewal Case:

  • Document improvement in headache frequency and severity
  • Show reduced emergency department visits
  • Demonstrate improved quality of life measures
  • Include any new clinical evidence supporting continued treatment

Quick Reference Checklist

Before Submitting:

  • Verify UnitedHealthcare/OptumRx coverage
  • Confirm prescriber is in-network
  • Check formulary status and step therapy requirements
  • Gather 3+ months of headache diary
  • Document at least 2 failed preventive medications
  • Collect all supporting clinical records

Submission Process:

  • Submit via UnitedHealthcare Provider Portal or call 1-800-711-4555
  • Include complete medical necessity letter
  • Attach all supporting documentation
  • Request expedited review if urgent
  • Document submission date and reference number

Follow-Up Actions:

  • Check status within 3-5 days
  • Respond promptly to additional information requests
  • Consider peer-to-peer review if initial denial
  • File appeal within 21 days if denied
  • Pursue external review if internal appeals fail

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Illinois? Standard prior authorization decisions typically take up to 15 business days. Expedited reviews for urgent cases can be completed within 24-72 hours. Always request expedited review if treatment delay could seriously impact your health.

What if Emgality is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and providing clinical rationale for why formulary alternatives are inappropriate. Include documentation of contraindications or failures of preferred alternatives.

Can I request an expedited appeal in Illinois? Yes, Illinois law provides for expedited appeals when treatment delay would seriously jeopardize your health. Expedited appeals must be decided within 24 hours, and external reviews can be completed in 24-72 hours for urgent cases.

Does step therapy apply if I failed medications outside Illinois? Yes, prior treatment failures from other states count toward step therapy requirements. Ensure your new Illinois provider has complete documentation of previous medication trials and outcomes.

What happens if I miss the 30-day external review deadline in Illinois? Illinois has a strict 30-day deadline for filing external review requests after final internal appeal denial. Missing this deadline typically forfeits your right to external review, so act promptly after receiving final denial letters.

Can I use manufacturer copay assistance while appealing? Yes, Eli Lilly offers copay assistance programs that may help with out-of-pocket costs while your appeal is pending. Visit emgality.lilly.com/savings-support for eligibility requirements and application information.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to identify denial reasons and draft point-by-point rebuttals aligned to each plan's specific requirements. For complex cases involving medications like Emgality, Counterforce Health can help streamline the appeals process with payer-specific workflows and evidence-based documentation.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider about treatment options and work with your insurance plan directly for coverage determinations. For additional assistance with insurance appeals in Illinois, contact the Illinois Department of Insurance at 877-527-9431 or visit insurance.illinois.gov.

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