How to Get Filsuvez Covered by UnitedHealthcare in Texas: Complete Prior Authorization Guide with Forms and Appeal Scripts

Answer Box: Getting Filsuvez Covered by UnitedHealthcare in Texas

Filsuvez requires prior authorization from UnitedHealthcare for epidermolysis bullosa treatment in Texas. Your fastest path to approval: (1) Confirm your diagnosis is dystrophic or junctional EB with genetic testing, (2) Document wound size (10-50 cm²) and duration (3+ weeks), and (3) Show you've tried or can't use Vyjuvek first due to step therapy requirements. Submit through the UnitedHealthcare Provider Portal with complete clinical documentation. Start today: Call your dermatologist to request genetic confirmation and wound measurements for your PA packet.


Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up Strategy
  6. Understanding UnitedHealthcare Timelines
  7. Handling Requests for Additional Information
  8. If Your Request Is Denied
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This comprehensive guide helps patients with epidermolysis bullosa (EB) and their healthcare teams navigate UnitedHealthcare's prior authorization process for Filsuvez (birch triterpenes topical gel) in Texas. Filsuvez, approved by the FDA in December 2024, treats wounds in junctional and dystrophic EB patients aged 6 months and older.

Who this helps:

  • Patients with confirmed dystrophic or junctional EB
  • Dermatologists and wound care specialists
  • Caregivers managing PA submissions
  • Families facing UnitedHealthcare denials

Expected outcomes: With proper documentation, most medically appropriate Filsuvez requests receive approval within 72 hours for urgent cases or 30 days for standard reviews.


Before You Start: Plan Verification

Confirm Your UnitedHealthcare Plan Type

Different UnitedHealthcare products have varying requirements:

Plan Type Key Differences Verification Method
Commercial/Employer Standard PA process Check member portal
Medicare Advantage May have additional step therapy Call member services
Medicaid (Texas) State-specific appeals rights Review plan documents

Action step: Log into your UnitedHealthcare member portal to verify your specific plan's formulary status for Filsuvez.

Verify Network Status

Ensure your prescribing physician is in-network with UnitedHealthcare. Out-of-network prescriptions face additional barriers and higher costs.

Pharmacy vs. Medical Benefit

Filsuvez is covered under the pharmacy benefit as a specialty medication, not the medical benefit. This means it requires specialty pharmacy dispensing and prior authorization through OptumRx.


Gather Required Documentation

Essential Clinical Documentation

Diagnosis Requirements:

  • Confirmed dystrophic EB (ICD-10: Q81.2) or junctional EB (ICD-10: Q81.1)
  • Genetic testing results showing relevant mutations:
    • Dystrophic EB: COL7A1 mutations
    • Junctional EB: LAMA3, LAMB3, LAMC2, COL17A1, ITGA6, ITGB4, or ITGA3 mutations

Wound Documentation:

  • At least one partial-thickness wound measuring 10-50 cm²
  • Wound present for minimum 3 weeks (but less than 9 months)
  • Confirmation that wound is clean and not infected
  • Photographic documentation (if possible)

Step Therapy Documentation: UnitedHealthcare requires documentation of Vyjuvek trial or contraindication:

  • Option A: Unsuccessful 3-month trial of Vyjuvek with specific outcomes
  • Option B: Clinical contraindication to Vyjuvek with detailed rationale
Note: Filsuvez and Vyjuvek cannot be used concurrently on the same wound.

Required Forms and Submissions

Prior Authorization Form: Access the current UnitedHealthcare Filsuvez PA form through the UnitedHealthcare Provider Portal. The form requires:

  • Patient demographics and insurance information
  • Prescriber specialty (dermatologist or wound care specialist required)
  • Complete clinical justification
  • Genetic testing confirmation

Submit Your Prior Authorization Request

Electronic Submission (Required as of August 2025)

Primary Method: UnitedHealthcare Provider Portal

  • All PA requests must be submitted electronically
  • Upload supporting documentation as PDF attachments
  • Track submission status in real-time

Portal Access: If you need portal assistance, contact UnitedHealthcare Web Support at 866-842-3278, option 1 (Mon-Fri, 7 a.m.-9 p.m. CT).

Clean Request Packet Checklist

✅ Completed PA form with all required fields
✅ Genetic testing results
✅ Wound measurements and photos
✅ Step therapy documentation (Vyjuvek trial or contraindication)
✅ Current clinical notes from dermatologist
✅ Patient insurance verification
✅ Prescriber DEA/NPI information

Specialty Pharmacy Routing

Once approved, Filsuvez will be dispensed through UnitedHealthcare's contracted specialty pharmacies. Your approval letter will include specific pharmacy contact information and next steps.


Follow-Up Strategy

When to Call UnitedHealthcare

  • Day 3: If no acknowledgment received for urgent requests
  • Day 7: For standard requests without initial response
  • Day 14: If additional information was requested but not specified

Sample Call Script for Patients

"Hi, I'm calling about a prior authorization request for Filsuvez for epidermolysis bullosa. My member ID is [ID number]. The request was submitted on [date] through the provider portal. Can you please provide the current status and reference number? If additional information is needed, what specific documents are required and what's the deadline for submission?"

Document everything: Keep a log with date, time, representative name, reference numbers, and next steps.


Understanding UnitedHealthcare Timelines

Texas-Specific Requirements

Request Type UnitedHealthcare Timeline Texas Law Backup
Urgent/Expedited 72 hours State law supports expedited review
Standard PA 30 days (pre-service) 180 days to file internal appeal
Appeal Response 30 days (standard), 72 hours (urgent) External review available after internal

What Speeds Decisions

  • Complete documentation on first submission
  • Clear genetic testing results
  • Specialist (dermatologist) prescriber
  • Urgent medical necessity documentation

What Slows Decisions

  • Missing genetic confirmation
  • Incomplete wound measurements
  • Lack of step therapy documentation
  • General practitioner prescriber (may require specialist consultation)

Handling Requests for Additional Information

Common Information Requests

Medical Necessity Questions:

  • "Provide detailed wound care history"
  • "Clarify why Vyjuvek is not appropriate"
  • "Submit updated wound measurements"

Response Strategy:

  1. Respond within 48 hours of request
  2. Provide specific, measurable clinical data
  3. Include relevant literature citations when appropriate
  4. Attach updated clinical notes if wound status has changed

Supporting Literature

Key references to include when strengthening your case:

  • FDA labeling for Filsuvez (official prescribing information)
  • Clinical trial data from manufacturer resources
  • Epidermolysis bullosa treatment guidelines from dermatology societies

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Genetic testing not confirmed" Submit complete genetic panel results Lab reports with specific mutations
"Step therapy not completed" Document Vyjuvek trial or contraindication Treatment records, adverse events
"Wound size outside criteria" Provide updated measurements Current clinical assessment
"Not medically necessary" Strengthen clinical justification Specialist letter, treatment history

Texas Appeals Process

Internal Appeal (First Level):

  • File within 180 days of denial
  • Submit via UnitedHealthcare Provider Portal
  • Include denial letter and additional evidence
  • Decision required within 30 days (72 hours if urgent)

External Review (If Internal Appeal Denied):

  • Available through Texas Department of Insurance
  • File within 4 months of final internal denial
  • Independent Review Organization (IRO) provides binding decision
  • Contact TDI at 1-800-252-3439 for assistance
Tip: For urgent cases, you can request expedited external review concurrently with internal appeal if delay would jeopardize health.

Peer-to-Peer Review Request

If facing denial, request a peer-to-peer review between your dermatologist and UnitedHealthcare's medical director:

Script for clinic staff: "We're requesting a peer-to-peer review for the Filsuvez denial. Dr. [Name] is available [times] to discuss the medical necessity with your reviewing physician. This is for a patient with confirmed dystrophic EB who meets all clinical criteria."


Renewal and Reauthorization

When to Start Renewal Process

Begin reauthorization 60 days before your current approval expires. UnitedHealthcare approvals for Filsuvez typically last 12 months.

Required Renewal Documentation

  • Updated wound assessments showing continued need
  • Treatment response documentation
  • Confirmation that alternative therapies remain inappropriate
  • Current clinical notes from treating specialist

Calendar reminder: Set alerts for 90 days and 60 days before expiration to ensure uninterrupted treatment.


Quick Reference Checklist

Before Submitting:

□ Genetic testing confirms dystrophic or junctional EB
□ Wound meets size criteria (10-50 cm²) and duration (3+ weeks)
□ Step therapy documented (Vyjuvez trial or contraindication)
□ Dermatologist or wound specialist is prescriber
□ All forms completed and signed

After Submission:

□ Reference number documented
□ Follow-up scheduled based on urgency
□ Additional information requests monitored
□ Appeal strategy prepared if needed

For Appeals:

□ Denial letter and reason code identified
□ Additional clinical evidence gathered
□ Texas appeal timeline confirmed (180 days)
□ External review option understood


FAQ

Q: How long does UnitedHealthcare prior authorization take for Filsuvez in Texas?
A: Urgent requests receive decisions within 72 hours; standard requests within 30 days. Complete documentation on first submission speeds approval.

Q: What if Filsuvez is not on my UnitedHealthcare formulary?
A: Non-formulary medications can still be covered with prior authorization and medical necessity documentation. The PA process addresses formulary placement.

Q: Can I request expedited review for Filsuvez?
A: Yes, if delaying treatment would jeopardize your health. Document medical urgency and request expedited processing when submitting.

Q: Does UnitedHealthcare step therapy apply if I tried Vyjuvek in another state?
A: Step therapy documentation from any location is typically accepted. Provide complete treatment records and outcomes.

Q: What if my dermatologist is out-of-network with UnitedHealthcare?
A: Out-of-network specialists can prescribe Filsuvez, but you may face higher costs and additional authorization requirements. Consider requesting a network exception.

Q: How much does Filsuvez cost with UnitedHealthcare coverage?
A: Costs vary by plan. With prior authorization approval, specialty tier copays typically apply. Contact member services for specific cost-sharing details.


About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals for prescription medications. The platform analyzes denial letters, identifies specific denial criteria, and creates targeted, evidence-backed rebuttals that align with each plan's requirements—including UnitedHealthcare's complex prior authorization processes for specialty medications like Filsuvez.

For families navigating EB treatment coverage, Counterforce Health can streamline the appeals process by automatically pulling relevant clinical evidence, FDA labeling, and payer-specific documentation requirements to strengthen your case.


Sources & Further Reading


Disclaimer: This guide provides general information about insurance processes and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan's specific requirements. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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