By Counterforce Health Team in Epidiolex (cannabidiol) —

How to Get Epidiolex (Cannabidiol) Covered by UnitedHealthcare in Michigan: Appeals, Forms & State Protections

Answer Box: Your Path to Epidiolex Coverage in Michigan

UnitedHealthcare requires prior authorization for Epidiolex (cannabidiol), with step therapy requirements varying by seizure disorder. For Dravet syndrome or tuberous sclerosis complex (TSC), approval is based on diagnosis alone. For Lennox-Gastaut syndrome (LGS), you'll need documented 8-week trials of two generic anticonvulsants first. If denied, Michigan's DIFS external review process gives you 127 days to appeal through an Independent Review Organization. Start today: Have your neurologist submit prior authorization through OptumRx (1-800-711-4555) with complete documentation.

Table of Contents

  1. Read Your Denial Letter
  2. UnitedHealthcare Prior Authorization Requirements
  3. Medical Necessity Letter Template
  4. First-Level Internal Appeal
  5. Peer-to-Peer Review Process
  6. Michigan External Review Through DIFS
  7. Common Denial Reasons & Solutions
  8. Cost Savings & Patient Support
  9. When to Escalate to State Regulators
  10. FAQ

Read Your Denial Letter

Your UnitedHealthcare denial letter contains critical information for your appeal. Look for these key elements:

Denial reason codes typically fall into these categories:

  • PA required: Prior authorization wasn't submitted
  • Step therapy: Must try preferred alternatives first
  • Non-formulary: Drug isn't on your plan's covered list
  • Quantity limits exceeded: Dose exceeds plan maximums
  • Not medically necessary: Clinical criteria weren't met

Extract these deadlines:

  • Internal appeal: Usually 180 days from denial date
  • Expedited appeal: Available for urgent medical needs (72 hours)
  • External review: 127 days after final internal denial (Michigan-specific)
Tip: UnitedHealthcare's denial letters include specific evidence needed and submission options (portal, fax, mail). Keep this information handy for your appeal.

UnitedHealthcare Prior Authorization Requirements

Coverage at a Glance

Requirement Dravet Syndrome Lennox-Gastaut Syndrome Tuberous Sclerosis Complex
Prior Authorization Yes Yes Yes
Step Therapy No Two 8-week trials required No
Genetic Testing SCN1A confirmation required Not required Not required
Documentation Diagnosis + seizure history Failed trials + clinical notes TSC diagnosis + seizure documentation

Source: UnitedHealthcare OptumRx Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Gather diagnosis documentation (patient/clinic): ICD-10 codes, genetic testing results, EEG/MRI reports
  2. Document prior medication trials (clinic): For LGS, minimum 8-week trials of two generic anticonvulsants with failure reasons
  3. Submit PA through OptumRx (prescriber): Call 1-800-711-4555 or use UnitedHealthcare Provider Portal
  4. Include clinical notes (prescriber): Seizure frequency, quality-of-life impact, medical necessity attestation
  5. Follow up in 5-7 days (patient/clinic): Standard decision timeline; expedited available for urgent cases
  6. Prepare for peer-to-peer (prescriber): If initially denied, schedule review with UHC medical director
  7. File appeal if denied (patient): Internal appeal first, then Michigan DIFS external review

Medical Necessity Letter Template

Clinician Corner: Essential Documentation

Your prescriber's medical necessity letter should include these components:

Patient History Section:

  • Specific seizure type and frequency
  • Developmental impact and functional limitations
  • Previous hospitalizations or emergency visits

Prior Treatment Documentation:

  • Complete list of failed antiseizure medications
  • Dosages, duration (minimum 8 weeks for LGS), and specific failure reasons
  • Contraindications to preferred alternatives

Clinical Rationale:

  • FDA approval for patient's specific condition
  • Published efficacy data supporting use
  • Proposed dosing and monitoring plan

Here's a sample framework from Jazz Pharmaceuticals:

[Date]
[Insurance Medical Director]

Re: [Patient Name] - Prior Authorization Request for EPIDIOLEX®

Dear Dr. [Medical Director],

I am requesting prior authorization for EPIDIOLEX® (cannabidiol) for my patient [Name], diagnosed with [specific seizure syndrome]. Despite trials of multiple antiseizure medications, seizures remain inadequately controlled.

**Clinical History:**
- Diagnosis: [LGS/Dravet/TSC] confirmed by [genetic testing/clinical criteria]
- Current seizure frequency: [specific details]
- Functional impact: [developmental, quality-of-life effects]

**Prior Failed Therapies:**
- [Medication 1]: [dose, duration, failure reason]
- [Medication 2]: [dose, duration, failure reason]

**Medical Necessity:**
EPIDIOLEX® is FDA-approved for [patient's condition] and represents the appropriate next step given inadequate response to standard therapies.

Attached: Medical records, diagnostic studies, prior authorization forms

Contact me at [phone] for questions.

Sincerely,
[Prescriber Name, Credentials]

Template adapted from TSC Alliance Sample Letter

First-Level Internal Appeal

What to Include in Your Appeal

Required Documents:

  • Copy of denial letter
  • Medical necessity letter from prescriber
  • Complete medical records supporting diagnosis
  • Documentation of prior medication failures
  • Any additional clinical evidence (lab results, imaging)

Structuring Your Appeal:

  1. Opening paragraph: State you're appealing the denial of Epidiolex coverage
  2. Medical necessity: Reference FDA approval for your specific condition
  3. Prior failures: Detail inadequate response to preferred alternatives
  4. Clinical guidelines: Cite relevant epilepsy treatment guidelines
  5. Conclusion: Request immediate approval with contact information

Submission Process

Online Portal: Log into your UnitedHealthcare member portal and upload documents By Mail: Send to address on your denial letter By Fax: Use fax number provided in denial notification

Note: Include "URGENT - APPEAL REQUEST" in subject lines for expedited processing when medically appropriate.

Peer-to-Peer Review Process

Before filing a formal appeal, request a peer-to-peer review where your neurologist discusses the case directly with a UnitedHealthcare medical director.

Scheduling Your Review

  1. Complete P2P Request Form (UMF0057) with prescriber details and three preferred time slots
  2. Submit via encrypted email to [email protected]
  3. Include time zones and role of requesting physician in patient care
  4. Timeline: Submit within 14 calendar days of denial for outpatient services

Preparation Checklist for Prescribers

  • Review patient's complete seizure history and medication trials
  • Have specific failure reasons and contraindications ready
  • Prepare to discuss FDA labeling and clinical guidelines
  • Reference published efficacy data for patient's condition
  • Be ready to propose monitoring plan and follow-up schedule

Source: UnitedHealthcare P2P Process Guide

Michigan External Review Through DIFS

If UnitedHealthcare upholds their denial after internal appeals, Michigan's Department of Insurance and Financial Services (DIFS) provides external review through Independent Review Organizations.

Real Case Example: Epidiolex Success

In 2025, DIFS overturned Blue Care Network's denial of Epidiolex for a child with generalized idiopathic epilepsy. The IRO (a board-certified pediatric neurologist) found the insurer's criteria inconsistent with standard care, ruling that off-label use was medically necessary for refractory epilepsy.

Source: Michigan DIFS External Review Decision

Filing Your External Review

Eligibility: Must complete internal grievance process first Timeline: 127 days from final internal denial (Michigan-specific extension) Cost: Free process

How to File:

  1. Online: Use DIFS External Review Form
  2. By Mail/Fax: Submit FIS 0018 form to DIFS
  3. Required Documents:
    • Insurer denial letter
    • Medical records
    • Physician letter of medical necessity
    • For off-label use: DIFS Treating Provider Certification form

Timeline: Standard reviews completed within 60 days; expedited reviews within 72 hours with physician attestation of urgency

Contact: Call DIFS at 877-999-6442 (M-F, 8am-5pm) for assistance

Source: Michigan DIFS Appeals Process

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document 8-week trials of two generic anticonvulsants Medication list with dates, doses, failure reasons
Dose exceeds quantity limits Show medical necessity for higher dose Clinical notes justifying dosing, weight-based calculations
Off-label use Demonstrate standard of care Published guidelines, peer-reviewed studies
Insufficient prior trials Provide complete medication history Pharmacy records, clinical notes, contraindication documentation
Missing genetic testing Submit diagnostic confirmation SCN1A testing for Dravet, clinical criteria for TSC/LGS

Cost Savings & Patient Support

JazzCares Patient Assistance

  • Copay assistance: Up to $200/month for commercially insured patients
  • Patient assistance program: Free drug for qualifying uninsured patients
  • Application: Available at JazzCares.com or call 1-800-394-4148

Alternative Coverage Options

  • Medicaid: Different prior authorization process through state Medicaid
  • Medicare Part D: May have different formulary placement
  • Manufacturer samples: Ask prescriber about starter supplies during appeals
From our advocates: We've seen families successfully navigate denials by working closely with their neurologist's office to ensure complete documentation. One Michigan family had their external review approved within 45 days after DIFS assigned a pediatric epilepsy specialist as their IRO reviewer. The key was including detailed seizure logs and comprehensive medication trial documentation.

When to Escalate to State Regulators

Contact Michigan DIFS if UnitedHealthcare:

  • Fails to respond within required timelines
  • Doesn't provide required appeal information
  • Continues denying after successful external review

Michigan DIFS Contact:

Counterforce Health helps patients navigate these complex appeals by turning denials into targeted, evidence-backed rebuttals. Our platform identifies the specific denial basis and drafts point-by-point responses aligned to your plan's own rules, pulling the right clinical evidence and citations to support your case. Visit CounterforceHealth.org to learn how we can help strengthen your appeal.

FAQ

How long does UnitedHealthcare prior authorization take in Michigan? Standard decisions take 5-7 business days; expedited reviews for urgent cases are completed within 72 hours.

What if Epidiolex is non-formulary on my plan? Non-formulary drugs require stronger justification of failed alternatives and may need medical exception requests beyond standard prior authorization.

Can I request an expedited appeal? Yes, if your doctor certifies that delays would jeopardize your health. Include physician attestation with your appeal.

Does step therapy apply if I tried medications outside Michigan? Yes, document all prior trials regardless of location. Include pharmacy records and clinical notes from previous providers.

What happens if I miss the 127-day external review deadline? Michigan's deadline is firm. Contact DIFS immediately if you're close to the deadline - they may provide guidance on exceptional circumstances.

Can my doctor file appeals for me? Yes, Michigan law allows physicians to file appeals with patient consent. This often results in more complete clinical documentation.

Are there alternatives if all appeals fail? Consider manufacturer patient assistance programs, clinical trials, or working with your neurologist to identify similar medications with different coverage criteria.

How successful are external reviews in Michigan? While DIFS doesn't publish aggregate success rates, documented cases show IRO reviewers with relevant medical expertise often overturn insurer denials when clinical evidence supports medical necessity.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan. Always consult with your healthcare provider and insurance plan directly. For personalized assistance with insurance appeals and coverage denials, CounterforceHealth.org provides expert guidance to help patients get their prescribed medications approved.

Sources & Further Reading

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