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

How to Get Eylea and Lucentis Covered by UnitedHealthcare in Texas: Prior Authorization Forms, Appeals, and Step Therapy Guide

Answer Box: Getting Started in Texas

UnitedHealthcare requires prior authorization for both Eylea (aflibercept) and Lucentis (ranibizumab) in Texas, with step therapy typically requiring bevacizumab first unless contraindicated. Both drugs are placed in Tier 4 (Specialty) with higher copays or coinsurance. Fastest approval path: (1) Have your retina specialist submit PA through the UnitedHealthcare Provider Portal with complete clinical documentation, (2) Include bevacizumab trial history or contraindication rationale, (3) If denied, file internal appeal within 60 days, then external IRO review within 4 months if needed.

Table of Contents

  1. Plan Types and Coverage Implications
  2. Formulary Status and Tier Placement
  3. Prior Authorization and Step Therapy Requirements
  4. Specialty Pharmacy Requirements
  5. Cost-Share Dynamics
  6. Submission Process and Documentation
  7. Appeals Process in Texas
  8. Common Denial Reasons and Solutions
  9. FAQ

Plan Types and Coverage Implications

UnitedHealthcare offers several plan types in Texas, each with different requirements for accessing Eylea and Lucentis:

Commercial Plans (HMO/PPO/EPO)

Medicare Advantage Plans

Medicaid Plans (STAR)

Formulary Status and Tier Placement

Both Eylea and Lucentis are consistently placed in the highest formulary tier across UnitedHealthcare plans in Texas:

Drug Formulary Tier Typical Cost-Share PA Required
Eylea (aflibercept) Tier 4 (Specialty) 20-33% coinsurance Yes
Lucentis (ranibizumab) Tier 4 (Specialty) 20-33% coinsurance Yes
Bevacizumab (off-label) Preferred alternative Lower cost-share May be required first

Coverage Indications Both medications are covered for FDA-approved uses including:

  • Neovascular (wet) age-related macular degeneration
  • Diabetic macular edema
  • Diabetic retinopathy
  • Retinal vein occlusion with macular edema

Prior Authorization and Step Therapy Requirements

Step Therapy Protocol

UnitedHealthcare typically requires patients to try bevacizumab (off-label) before approving Eylea or Lucentis, unless:

  • Patient has documented contraindication to bevacizumab
  • Previous bevacizumab treatment failed or caused intolerance
  • Clinical circumstances make bevacizumab inappropriate

Documentation Requirements

Your retina specialist must submit:

  • Diagnosis confirmation with ICD-10 codes
  • Retinal imaging (OCT, fluorescein angiography)
  • Visual acuity measurements
  • Prior treatment history including bevacizumab trial or contraindication rationale
  • Treatment plan with dosing frequency and monitoring schedule
Clinician Corner: Medical necessity letters should reference current clinical guidelines (American Academy of Ophthalmology, American Society of Retina Specialists) and include specific visual acuity measurements, central retinal thickness from OCT, and clear documentation of treatment response or failure with alternative agents.

Specialty Pharmacy Requirements

Both Eylea and Lucentis require dispensing through UnitedHealthcare's specialty pharmacy network:

For Commercial Plans

  • OptumRx specialty pharmacy typically handles fulfillment
  • Provider administers in-office after specialty pharmacy delivery
  • Patient coordinates delivery timing with injection appointments

For Medicare Advantage

  • Covered under Part B as provider-administered drugs
  • No specialty pharmacy requirement for Part B coverage
  • Provider obtains directly from manufacturer or distributor

Cost-Share Dynamics

Commercial Plans

  • Deductible applies before copay/coinsurance kicks in
  • Tier 4 specialty copays: Often $40-60+ per injection
  • Coinsurance alternative: 20-33% of drug cost (can be $240-800+ per injection)
  • Out-of-pocket maximum provides annual cost cap

Medicare Advantage

  • Part B coinsurance: Typically 20% after Part B deductible
  • No specialty pharmacy copay since covered under Part B
  • Supplemental coverage may reduce patient responsibility
Note: Actual costs vary significantly by specific plan. Always verify your exact benefits through the member portal or by calling the number on your insurance card.

Submission Process and Documentation

Provider Portal Submission

Providers must use the UnitedHealthcare Provider Portal for PA requests:

  1. Log in with One Healthcare ID
  2. Select "Prior Authorization and Notification"
  3. Complete OptumRx specialty drug form
  4. Attach required clinical documentation
  5. Submit and track status online

Alternative Submission Methods

  • Fax: 877-940-1972
  • Phone support: Available through provider portal
  • Chat service: Accessible via UHCprovider.com

Required Documentation Checklist

  • Completed PA form with patient demographics
  • Diagnosis with ICD-10 codes
  • Current clinical notes from retina specialist
  • Recent OCT and visual acuity measurements
  • Documentation of bevacizumab trial or contraindication
  • Treatment plan with injection frequency
  • Prescriber DEA and NPI numbers

Appeals Process in Texas

If your initial PA request is denied, Texas law provides strong appeal rights:

Internal Appeals Timeline

  • Filing deadline: 60 days from denial notice
  • Standard appeals: Decision within 30 days
  • Expedited appeals: Decision within 72 hours for urgent cases
  • Submission: Through member portal, phone, mail, or fax

External Review (IRO) Process

Texas residents have the right to independent external review:

  • Eligibility: Available after internal appeal denial
  • Filing deadline: 4 months from final internal denial
  • Timeline: 20 days for standard review, 5 days for urgent
  • Cost: Free to patient (insurer pays IRO fees)
  • Binding: UnitedHealthcare must comply with IRO decisions

How to Request External Review

  1. Use IRO form included with final denial letter
  2. Contact Texas Department of Insurance: 1-800-252-3439
  3. Submit online via TDI website
  4. Include all documentation: medical records, denial letters, appeal history

For complex cases, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not completed Document bevacizumab trial or contraindication Prior treatment records, allergy documentation
Insufficient clinical evidence Provide comprehensive imaging and VA data Recent OCT, FA, visual field testing
Quantity/frequency limits Justify dosing per FDA label and guidelines Treatment protocol, response monitoring
Not medically necessary Strengthen clinical rationale with guidelines Peer-reviewed literature, society recommendations
Missing prior authorization Resubmit with complete documentation All required forms and clinical notes
From Our Advocates: In our experience with Texas UnitedHealthcare cases, the most successful appeals include a clear timeline of previous treatments, specific visual acuity improvements or stability data, and direct quotes from ophthalmology society treatment guidelines that support the requested therapy. This composite approach has helped many patients access needed retinal treatments.

FAQ

How long does UnitedHealthcare prior authorization take in Texas? Standard PA decisions are made within 30 days, but urgent cases can be expedited to 72 hours. OptumRx's automation program may reduce approval times for eligible drugs to under a minute.

What if Eylea or Lucentis is non-formulary on my plan? Both drugs are typically covered on UnitedHealthcare formularies as specialty tier medications. If non-formulary, you can request a formulary exception with strong medical necessity documentation.

Can I request an expedited appeal in Texas? Yes, if delays would jeopardize your health or vision, you can request expedited internal appeals (72-hour decision) and expedited external review (5-day decision).

Does step therapy apply if I tried bevacizumab outside Texas? Yes, documented bevacizumab trials from any location should satisfy step therapy requirements. Ensure your new Texas provider has complete treatment records.

What's the difference between Medicare and commercial coverage? Medicare Advantage covers these drugs under Part B with 20% coinsurance after deductible. Commercial plans use specialty pharmacy with higher tier copays or coinsurance.

How much will I pay out-of-pocket? Costs vary widely by plan. Specialty tier drugs may cost $40-60+ copay or 20-33% coinsurance ($240-800+ per injection). Check your specific benefits or call member services.

Can I appeal if UnitedHealthcare requires too many injections be denied? Yes, if clinical guidelines support more frequent dosing than approved, you can appeal quantity limits with supporting medical literature and treatment response data.

Where can I get help with appeals in Texas? Contact the Texas Department of Insurance at 1-800-252-3439, or organizations like Counterforce Health that specialize in insurance appeal strategies.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always consult your healthcare provider about treatment decisions and verify current benefits with UnitedHealthcare directly.

Sources & Further Reading

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