By Counterforce Health Team in Hemgenix (etranacogene dezaparvovec) —

How to Get Hemgenix (etranacogene dezaparvovec) Covered by UnitedHealthcare in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Hemgenix Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for Hemgenix (etranacogene dezaparvovec) in Washington but does not mandate step therapy with alternative therapies. To get approval: 1) Verify eligibility (age 18+, severe hemophilia B, 50+ factor IX exposure days, negative inhibitors), 2) Submit PA through UnitedHealthcare Provider Portal with complete documentation, 3) If denied, file internal appeals within 180 days, then external review through Washington's Office of the Insurance Commissioner within 60 days. Washington's external review has strong consumer protections with binding decisions.

Table of Contents

  1. Verify Your Plan and Find the Correct Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Tools
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Coordination
  6. Support Lines and Case Management
  7. Washington State Appeals and External Review
  8. Common Denial Reasons and Solutions
  9. Keeping Resources Current

Verify Your Plan and Find the Correct Forms

Before starting your Hemgenix prior authorization, confirm your specific UnitedHealthcare plan type. Coverage criteria and forms vary between commercial plans, Medicare Advantage, and Medicaid managed care plans.

Plan Verification Steps:

  1. Check your member ID card for plan type (commercial, Medicare Advantage, or Medicaid)
  2. Call UnitedHealthcare member services at 1-800-356-3477 to confirm specialty drug benefits
  3. Verify your hemophilia treatment center is in-network through the UnitedHealthcare provider directory
Note: UnitedHealthcare requires treatment at a certified hemophilia treatment center within their network for Hemgenix coverage.

Prior Authorization Forms and Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all patients UnitedHealthcare Provider Portal UHC Gene Therapy Policy
Age Restriction 18 years or older Medical records UHC Gene Therapy Policy
Diagnosis Severe/moderately severe hemophilia B (≤2% Factor IX activity) Lab results UHC Gene Therapy Policy
Exposure Days Minimum 50 Factor IX exposure days Treatment history logs UHC Gene Therapy Policy
Inhibitor Status Negative (<0.6 Bethesda units) Recent inhibitor screen UHC Gene Therapy Policy
Liver Function Normal baseline ALT/AST Lab results within 30 days UHC Gene Therapy Policy

Required Documentation Checklist

Patient Information:

  • Full name, date of birth, UnitedHealthcare member ID
  • Patient weight in kilograms (for dosage calculation)
  • Prescribing physician and treatment center information

Clinical Documentation:

  • ICD-10 code D67 (hereditary factor IX deficiency) with supporting medical records
  • Factor IX activity levels (baseline without replacement therapy)
  • Inhibitor screen results (confirming negative status <0.6 Bethesda units)
  • Complete liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
  • Detailed treatment history documenting 50+ factor IX exposure days
  • Bleeding history including annualized bleeding rate
  • Current prophylaxis regimen details

Medical Necessity Letter Requirements: Your prescribing physician must include:

  • Confirmed hereditary factor IX deficiency diagnosis
  • Documented bleeding history despite current prophylaxis
  • Clinical rationale for Hemgenix appropriateness
  • Post-infusion monitoring and follow-up plan
  • Assessment of contraindications

Submission Portals and Online Tools

UnitedHealthcare Provider Portal

Submit your Hemgenix prior authorization through the UnitedHealthcare Provider Portal using the Specialty Pharmacy Transactions tool. This portal allows you to:

  • Upload all required documentation
  • Track authorization status
  • Receive real-time updates on your request

OptumRx Electronic Prior Authorization

For specialty medications, you can also use the OptumRx e-PA portal which offers:

  • Electronic submission capabilities
  • Automated status updates
  • Integration with electronic health records
Tip: Create accounts on both portals before submitting to ensure you have backup submission options.

Fax Numbers and Mailing Addresses

Prior Authorization Contacts

OptumRx Prior Authorization:

Specialty Pharmacy Support:

  • Optum Specialty Pharmacy: 1-855-427-4682 (24/7 support)
  • Prior Authorization Fax: 866-940-7328

Appeals and Grievances

Internal Appeals (plan-specific fax numbers):

  • Medicare Advantage plans: 866-373-1081
  • Individual Exchange plans: 888-808-9123
  • Provider Services: 800-600-9007
Important: Always call the main number first to confirm the correct fax number for your specific plan, as these can vary by state and plan type.

Specialty Pharmacy Coordination

Optum Specialty Pharmacy Services

UnitedHealthcare partners with Optum Specialty Pharmacy for Hemgenix distribution. Key services include:

Patient Support:

  • 24/7 phone support at 1-855-427-4682
  • Financial assistance coordination
  • Insurance benefit verification
  • Clinical support and education

Provider Support:

  • Prescription transfer assistance
  • Prior authorization support
  • Delivery coordination to treatment centers
  • Clinical consultation services

Transfer Process

  1. Prescription Transfer: Call 1-855-427-4682 to initiate transfer from your current pharmacy
  2. Benefit Verification: Optum will verify your UnitedHealthcare benefits
  3. Delivery Coordination: Schedule delivery to your treatment center
  4. Clinical Support: Access to pharmacists and nurses for questions

Support Lines and Case Management

Member Services

UnitedHealthcare Member Services:

  • Phone: 1-800-356-3477 (24/7)
  • Use for: Benefit verification, claim status, general coverage questions

What to Ask Member Services:

  • "Is Hemgenix covered under my plan?"
  • "What is my specialty drug copay or coinsurance?"
  • "Do I need prior authorization for Hemgenix?"
  • "Is my hemophilia treatment center in-network?"

Provider Services

UnitedHealthcare Provider Services:

  • Commercial plans: Contact through provider portal
  • Medicare Advantage: 800-600-9007
  • Use for: Prior authorization status, appeals, clinical reviews

Case Management

For complex cases, request a case manager through UnitedHealthcare Provider Services. Case managers can:

  • Expedite prior authorization reviews
  • Coordinate with specialty pharmacy
  • Assist with appeals documentation
  • Facilitate peer-to-peer reviews

Washington State Appeals and External Review

Washington state offers strong consumer protections for insurance denials through a comprehensive appeals process.

Internal Appeals Process

Timeline: File within 180 days of denial Levels: UnitedHealthcare requires at least one internal appeal level Submission: Use UnitedHealthcare Provider Portal or fax to plan-specific numbers above

External Review Process

If your internal appeals are unsuccessful, Washington law provides for external review by certified independent review organizations.

Key Details:

  • Deadline: 60 days from final internal denial
  • Timeline: 20 days for fully-insured plans, 45 days for self-insured plans
  • Expedited: 72 hours for urgent medical situations
  • Cost: No charge to you
  • Decision: Binding on UnitedHealthcare

Washington Office of the Insurance Commissioner

Contact Information:

  • Consumer Advocacy: 1-800-562-6900
  • Website: insurance.wa.gov
  • Services: Appeal guidance, template letters, complaint filing

The Office of the Insurance Commissioner can:

  • Explain your appeal rights
  • Provide template appeal letters
  • Guide you through the external review process
  • Investigate insurance company practices
Washington Advantage: The state's external review process is particularly effective for rare disease medications, with medical experts from research institutions often serving as reviewers.

Common Denial Reasons and Solutions

Denial Reasons and Fixes

Denial Reason How to Overturn Required Documents
Insufficient exposure days Compile complete treatment history Pharmacy records, infusion logs, medical records
Missing baseline labs Submit all required test results Factor IX levels, inhibitor screen, liver function tests
No documented treatment failure Document bleeding episodes and current therapy inadequacy ER visit records, bleeding logs, current regimen details
Non-network facility Verify treatment center network status Provider directory confirmation, network letter
Not medically necessary Strengthen clinical justification Peer-reviewed literature, expert opinion, treatment guidelines

Appeals Documentation Strategy

When appealing a denial, include:

  1. Complete medical records showing hemophilia B diagnosis and severity
  2. Treatment failure documentation demonstrating inadequate control with current therapy
  3. Clinical literature supporting Hemgenix use in your specific situation
  4. Expert opinion from your hemophilia specialist
  5. Quality of life impact statements showing how current treatment affects daily life

Keeping Resources Current

Healthcare coverage policies and contact information change frequently. To ensure you have the most current information:

Monthly Checks:

  • Review UnitedHealthcare provider portal for policy updates
  • Verify fax numbers and contact information
  • Check for new prior authorization forms

Quarterly Reviews:

  • Review Washington state insurance regulations for changes
  • Update contact information for Washington Office of the Insurance Commissioner
  • Check for new patient assistance programs

Annual Updates:

  • Review your UnitedHealthcare plan benefits during open enrollment
  • Verify your hemophilia treatment center remains in-network
  • Update all emergency contact information

Counterforce Health Support

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to the plan's own rules. For Hemgenix cases specifically, they can help gather the right citations from FDA labeling, peer-reviewed studies, and specialty guidelines while ensuring all required clinical facts are properly documented.

FAQ

How long does UnitedHealthcare prior authorization take in Washington? Standard review takes 5-14 business days. Expedited review (for urgent medical situations) takes 72 hours. Authorization is valid for up to 45 days from approval.

What if Hemgenix is non-formulary on my plan? Even if non-formulary, UnitedHealthcare must consider medical necessity appeals. Work with your physician to document why Hemgenix is medically necessary despite formulary status.

Can I request an expedited appeal in Washington? Yes, if your condition involves emergency services or poses serious health risks, you can request expedited review taking 72 hours instead of the standard timeline.

Does step therapy apply to Hemgenix? No, UnitedHealthcare does not mandate step therapy with alternative therapies as a prerequisite for Hemgenix approval, though you must meet all clinical eligibility criteria.

What happens if my external review is denied? While the external review decision is binding on UnitedHealthcare, you can still contact the Washington Office of the Insurance Commissioner for additional guidance or file complaints about insurance practices.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for the most current coverage information. For additional help with insurance appeals in Washington, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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