By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea and Lucentis Covered by UnitedHealthcare in Georgia: Prior Authorization Guide and Appeal Process

Answer Box: Get Eylea or Lucentis Covered by UnitedHealthcare in Georgia

UnitedHealthcare requires prior authorization for both Eylea and Lucentis in Georgia. Your retina specialist must submit documentation including diagnosis codes, OCT imaging, visual acuity measurements, and evidence of bevacizumab trial or contraindication. First step today: Contact your eye doctor to ensure they have your complete treatment history and can submit the PA request through the UnitedHealthcare Provider Portal. If denied, you have 180 days for internal appeal, then 60 days for external review through the Georgia Department of Insurance.

Table of Contents

Plan Types & Network Requirements

UnitedHealthcare offers different plan structures in Georgia, each with specific requirements for accessing retina specialists and getting Eylea or Lucentis covered.

Referral Requirements by Plan Type

Plan Type Referral Needed? Network Rules
HMO Yes, from PCP In-network specialist required
PPO No In-network preferred, out-of-network higher costs
EPO Yes, from PCP In-network specialist required

For HMO and EPO members: Your primary care provider must submit a referral before your retina specialist visit. The specialist must be in UnitedHealthcare's network for coverage.

For PPO members: You can see any retina specialist directly, but staying in-network reduces your out-of-pocket costs significantly.

Tip: Use the UnitedHealthcare Provider Directory to confirm your retina specialist is in-network before scheduling.

Formulary Status & Coverage

Both Eylea (aflibercept) and Lucentis (ranibizumab) are covered by UnitedHealthcare in Georgia, but with important restrictions.

Coverage at a Glance

Requirement Eylea Lucentis Where to Verify
Prior Authorization Required Required UHC Provider Portal
Formulary Tier Tier 4 (Specialty) Tier 4 (Specialty) Plan formulary document
Step Therapy Yes (bevacizumab first) Yes (bevacizumab first) Clinical policy
Quantity Limits Per injection schedule Per injection schedule Pharmacy benefits
Site of Care Physician office only Physician office only Medical policy

Covered Indications

UnitedHealthcare covers both medications for these FDA-approved conditions:

  • Neovascular (wet) age-related macular degeneration (AMD)
  • Diabetic macular edema
  • Diabetic retinopathy
  • Macular edema following retinal vein occlusion
  • Myopic choroidal neovascularization (Lucentis only)
  • Retinopathy of prematurity (Eylea only)

Prior Authorization Requirements

Prior authorization is mandatory for both Eylea and Lucentis before treatment can begin. Your retina specialist handles this process, but understanding the requirements helps ensure approval.

Required Documentation

Your doctor must provide:

  1. Diagnosis Information
    • Specific ICD-10 codes (e.g., H35.32 for wet AMD, E11.311 for diabetic macular edema)
    • Clinical notes supporting the diagnosis
  2. Imaging and Testing
    • Optical coherence tomography (OCT) results
    • Fluorescein angiography (if applicable)
    • Visual acuity measurements
    • Fundus photography
  3. Treatment History
    • Previous therapies tried and outcomes
    • Documentation of bevacizumab trial or contraindication
    • Response to prior anti-VEGF treatments
  4. Treatment Plan
    • Proposed dosing schedule
    • Monitoring plan
    • Treatment goals and expected outcomes

Submission Process

Providers submit PA requests through:

Processing times:

  • Standard requests: 72 hours
  • Expedited requests: 24 hours (for urgent medical situations)

Step Therapy & Alternatives

UnitedHealthcare typically requires patients to try bevacizumab (Avastin) before approving Eylea or Lucentis. This policy, called step therapy, aims to use the most cost-effective treatment first.

Step Therapy Exceptions

You can bypass bevacizumab if your doctor documents:

  • Medical contraindication to bevacizumab
  • Previous treatment failure with bevacizumab
  • Intolerance to bevacizumab with specific adverse effects
  • Clinical circumstances where bevacizumab is inappropriate

Alternative Medications

If Eylea or Lucentis are denied, other covered options may include:

  • Vabysmo (faricimab) - newer anti-VEGF with extended dosing
  • Beovu (brolucizumab) - for wet AMD and diabetic macular edema
  • Off-label bevacizumab - most cost-effective option

Counterforce Health helps patients and clinicians navigate these complex step therapy requirements by analyzing denial letters and crafting targeted appeals that address UnitedHealthcare's specific criteria.

Specialty Pharmacy Process

Anti-VEGF injections like Eylea and Lucentis are administered in your doctor's office, but the medication itself comes through UnitedHealthcare's specialty pharmacy network.

How It Works

  1. Provider orders medication after PA approval
  2. OptumRx or Accredo (UnitedHealthcare's specialty pharmacies) receives the order
  3. Medication is shipped directly to your doctor's office
  4. You receive injection during your scheduled appointment

Patient Enrollment

Some specialty pharmacies require patient enrollment:

  • Accredo: Call 877-222-7336 for enrollment
  • OptumRx: Enrollment typically handled by provider
  • Required information: Insurance details, contact information, injection schedule
Note: The medication is billed under your medical benefit, not pharmacy benefit, since it's administered by a healthcare provider.

Appeals Process in Georgia

If your prior authorization is denied, Georgia law provides specific rights and timelines for appeals.

Internal Appeal Process

Timeline: Must file within 180 days of denial notice

How to file:

  1. Gather documents: Denial letter, medical records, doctor's letter of medical necessity
  2. Submit appeal via UnitedHealthcare member portal or certified mail
  3. Include new evidence if available (additional imaging, peer-reviewed studies, clinical guidelines)

Processing time:

  • Standard review: 30 days
  • Expedited review: 72 hours (for urgent situations)

External Review Through Georgia DOI

If your internal appeal is denied, Georgia law provides an independent external review process.

Key details:

  • Deadline: 60 days from final internal denial
  • Cost: Free to patients
  • Contact: Georgia Department of Insurance at 1-800-656-2298
  • Process: Independent physicians review your case
  • Timeline: 30 business days (72 hours for expedited)
  • Binding: UnitedHealthcare must comply with favorable decisions

Required Documentation for Appeals

Strong appeals include:

  • Complete medical records with imaging results
  • Physician letter explaining medical necessity
  • Clinical evidence from peer-reviewed studies
  • Treatment history showing failed alternatives
  • Comparison with FDA labeling and clinical guidelines

Common Denial Reasons & Solutions

Denial Reason How to Address Required Documentation
Missing OCT imaging Submit recent OCT results OCT report within 30-90 days
Inadequate visual acuity documentation Provide detailed VA measurements ETDRS or Snellen chart results
Step therapy not completed Document bevacizumab contraindication Medical records showing adverse effects
Frequency exceeds limits Justify injection schedule Clinical notes supporting dosing
Not medically necessary Strengthen clinical rationale Guidelines from AAO or ASRS

From Our Advocates

"We've seen UnitedHealthcare approvals increase significantly when providers include specific visual acuity measurements and detailed OCT analysis in their initial PA requests. Many denials stem from incomplete documentation rather than true medical necessity issues. Taking time to gather comprehensive imaging and treatment history upfront prevents delays and appeals."

Cost-Sharing Considerations

Understanding your potential costs helps with financial planning and exploring assistance options.

Typical Cost Structure

  • Tier 4 specialty medications often have:
    • Higher copays ($50-$100+ per injection)
    • Or coinsurance (20-40% of drug cost)
    • May count toward specialty deductible

Financial Assistance Options

Manufacturer Programs:

Other Resources:

  • Georgia Department of Community Health - for Medicaid/PeachCare questions
  • Georgians for a Healthy Future - consumer assistance nonprofit
  • Patient Advocate Foundation - copay relief programs

When navigating these financial assistance programs, Counterforce Health can help identify the most appropriate resources based on your specific insurance situation and income level.

FAQ

How long does UnitedHealthcare prior authorization take in Georgia? Standard PA requests are processed within 72 hours. Expedited requests for urgent medical situations are completed within 24 hours.

What if Eylea or Lucentis is non-formulary on my plan? Both medications are typically covered but may require step therapy. If truly non-formulary, your doctor can request a formulary exception with medical justification.

Can I request an expedited appeal? Yes, if your medical condition could worsen significantly during normal processing times. Your doctor must document the urgency.

Does step therapy apply if I've used these medications outside Georgia? Treatment history from other states counts toward step therapy requirements. Provide documentation of previous bevacizumab use or contraindications.

What happens if I miss the 60-day external review deadline? Georgia's 60-day deadline is strict. However, you may still file a complaint with the Georgia Department of Insurance for other violations or seek legal counsel.

How do I find a retina specialist in UnitedHealthcare's network? Use the provider directory on UnitedHealthcare's website. Search for "ophthalmology" and filter for retinal specialists.

Can I appeal if my injection frequency is reduced? Yes, if your doctor believes more frequent injections are medically necessary. The appeal should include clinical evidence supporting the proposed schedule.

What if my employer plan has different rules? Self-funded employer plans may have different policies than standard UnitedHealthcare plans. Check your Summary Plan Description or contact HR for specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for decisions about your specific situation. For personalized assistance with prior authorizations and appeals, consider consulting with healthcare coverage advocates or legal professionals familiar with Georgia insurance law.

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