How to Get Eylea and Lucentis Covered by UnitedHealthcare in California: Complete Prior Authorization and Appeal Guide
Quick Answer: UnitedHealthcare requires prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab) in California. Submit requests through the UnitedHealthcare Provider Portal with OCT imaging, visual acuity measurements, and diagnosis documentation. If denied, file an internal appeal within 30 days, then request a California DMHC Independent Medical Review for binding external review. Start by calling UnitedHealthcare member services at 1-800-464-0123 to verify your specific plan's requirements.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Process in California
- Documentation Requirements
- Cost-Saving Options
- When to Contact California Regulators
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization Required | Yes, for both medical and pharmacy benefits | UnitedHealthcare PA Requirements |
| Formulary Status | Typically Tier 3-4 specialty drugs | Member portal or call 1-800-464-0123 |
| Step Therapy | May require bevacizumab trial first | Plan-specific; check member benefits |
| Diagnosis Requirements | Wet AMD, diabetic macular edema, or other FDA-approved indications | UHC Ophthalmologic VEGF Policy |
| Imaging Required | OCT showing fluid; FFA may be needed | Clinical documentation requirements |
| Appeal Deadline | 30 days for internal; no time limit for CA external review | UHC Appeals Process |
Step-by-Step: Fastest Path to Approval
1. Verify Coverage and Requirements
Who: Patient or clinic staff
Action: Log into the UnitedHealthcare member portal or call 1-800-464-0123
Timeline: Same day
What to confirm: Prior authorization requirements, formulary tier, any step therapy requirements
2. Gather Required Documentation
Who: Retina specialist and clinic staff
Documents needed:
- Recent OCT imaging showing intraretinal/subretinal fluid
- Best-corrected visual acuity measurements
- Fluorescein angiography (if available)
- Prior treatment history and outcomes
- Complete eye exam notes with diagnosis
3. Submit Prior Authorization Request
Who: Healthcare provider
How: UnitedHealthcare Provider Portal or OptumRx portal
Timeline: Submit at least 72 hours before planned treatment
Include: All clinical documentation, proposed treatment plan, and medical necessity justification
4. Follow Up on Decision
Timeline: Standard PA decisions within 72 hours; urgent requests within 24 hours
Action: Check portal status or call OptumRx at 1-800-711-4555
5. If Denied: Request Peer-to-Peer Review
Who: Prescribing physician
Timeline: Within 21 days of denial
Process: Call OptumRx to speak directly with reviewing physician
6. File Internal Appeal if Necessary
Timeline: Within 30 days of denial
Documents: Updated clinical notes, additional imaging, specialist letter supporting medical necessity
7. Escalate to California External Review
Who: Patient or provider
When: After internal appeal denial or 30 days without response
Process: File with California DMHC for Independent Medical Review
Clinician Corner: Medical Necessity Letter Checklist
Your appeal letter should include:Specific diagnosis with ICD-10 codes (H35.32x for wet AMD, E11.3xxx for diabetic retinopathy)Baseline and current visual acuity measurementsOCT findings showing central macular thickness and fluidPrior treatment failures or contraindications to alternativesReference to FDA labeling for approved indicationsTreatment plan and expected monitoring schedule
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn |
|---|---|
| "Step therapy not completed" | Document contraindications to bevacizumab or prior failure; request exception based on clinical urgency |
| "Insufficient visual acuity documentation" | Submit recent BCVA measurements with dates; include refraction if relevant |
| "Missing imaging requirements" | Provide OCT showing central macular thickness >300 microns or intraretinal/subretinal fluid |
| "Frequency exceeds policy limits" | Document disease progression or inadequate response; cite treat-and-extend protocols |
| "Not medically necessary" | Submit specialist letter with guideline references and expected outcomes |
Appeals Process in California
Internal Appeal with UnitedHealthcare
Timeline: 30 days from denial notice
How to file: UnitedHealthcare appeals portal or mail to address on denial letter
Required documents: Denial letter, medical records, physician statement of medical necessity
Decision timeline: 30 days for standard; 72 hours for urgent
California Independent Medical Review (IMR)
When: After internal appeal denial or 30 days without response
Who oversees: California Department of Managed Health Care (DMHC)
How to apply: DMHC online application or call 1-888-466-2219
Timeline: 45 days for standard; 7 days for urgent
Cost: Free to patients
Decision: Binding on UnitedHealthcare
Note: California's IMR process has historically shown high success rates for medically necessary specialty drugs when proper documentation is provided.
Documentation Requirements
For Initial Prior Authorization
- Patient Information: Member ID, date of birth, prescriber NPI
- Clinical Documentation:
- Confirmed diagnosis with ICD-10 codes
- Best-corrected visual acuity (both eyes, with dates)
- OCT imaging showing macular edema or fluid
- Treatment history and response to prior therapies
- Proposed Treatment: Drug name, dose, frequency, duration
For Appeals
- Additional Evidence:
- Specialist consultation notes
- Updated imaging showing disease progression
- Literature supporting off-label use (if applicable)
- Patient-specific factors requiring this medication
Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting targeted, evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements while ensuring all necessary documentation is included for maximum approval chances.
Cost-Saving Options
Manufacturer Support Programs
- Eylea: Regeneron Patient Assistance Program - up to $15,000 annual benefit for eligible patients
- Lucentis: Genentech Access Solutions - copay assistance and patient assistance programs
State and Foundation Programs
- California Prescription Drug Discount Program: Available for uninsured residents
- Patient Access Network Foundation: Provides copay assistance for retinal diseases
- Good Days: Offers financial assistance for chronic disease medications
Alternative Options
If brand-name drugs remain unaffordable, discuss these FDA-approved alternatives with your retina specialist:
- Ranibizumab biosimilars (Byooviz, Cimerli)
- Off-label bevacizumab (significantly lower cost)
When to Contact California Regulators
Contact DMHC If:
- UnitedHealthcare doesn't respond to appeals within required timeframes
- You need help filing an IMR application
- The plan isn't following California insurance laws
DMHC Help Center: 1-888-466-2219
Online: healthhelp.ca.gov
Contact CDI If:
Your plan is regulated by the California Department of Insurance (some PPO plans)
CDI Consumer Hotline: 1-800-927-4357
Frequently Asked Questions
Q: How long does UnitedHealthcare prior authorization take in California? A: Standard requests are processed within 72 hours. Urgent requests (when delay could seriously harm vision) are processed within 24 hours.
Q: What if Eylea or Lucentis isn't on my formulary? A: Request a formulary exception with supporting documentation from your retina specialist. If denied, this can be appealed through the same process.
Q: Can I get an expedited appeal for vision-threatening conditions? A: Yes. Both UnitedHealthcare and California's IMR process offer expedited reviews for urgent medical situations where delay could cause permanent vision loss.
Q: Does step therapy apply if I've failed bevacizumab outside California? A: Prior treatment failures from other states should be documented and submitted with your PA request. UnitedHealthcare typically accepts this documentation.
Q: What happens if my appeal is approved? A: UnitedHealthcare must authorize the treatment and provide retroactive coverage if you've already received care. The approval typically covers a specific number of treatments over a defined period.
Q: Can I continue treatment while appealing? A: You may continue treatment at your own expense, but UnitedHealthcare won't provide retroactive coverage unless the appeal is successful.
Q: How much do these medications cost without insurance? A: Eylea typically costs $1,200-$2,000 per injection, while Lucentis ranges from $1,500-$2,500 per injection, depending on the specific product and dosage.
Q: What's the success rate for appeals in California? A: While specific statistics for these medications aren't published, California's IMR process historically shows favorable outcomes for medically necessary treatments when proper documentation is provided.
This guide is for informational purposes only and doesn't constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage details. For additional help with insurance appeals and prior authorization, Counterforce Health provides specialized assistance in turning denials into approvals.
Sources & Further Reading
- UnitedHealthcare Prior Authorization Requirements (PDF)
- UHC Ophthalmologic VEGF Inhibitors Policy
- California DMHC Independent Medical Review
- UnitedHealthcare Appeals Process
- OptumRx Prior Authorization Guidelines
- FDA Eylea Prescribing Information
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