By Counterforce Health Team in Kesimpta (ofatumumab) —

How to Get Kesimpta (Ofatumumab) Covered by UnitedHealthcare in California: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Kesimpta Covered by UnitedHealthcare in California

UnitedHealthcare requires prior authorization for Kesimpta (ofatumumab) through OptumRx, with step therapy mandating documented failure of preferred MS treatments first. Submit PA via the UHC Provider Portal or fax to 1-844-403-1027. If denied, file internal appeals within 180 days, then request California's Independent Medical Review (IMR) through DMHC within 6 months. First step today: Verify your plan's formulary status and gather documentation of prior DMT failures at uhcprovider.com or by calling OptumRx at 1-800-711-4555.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Instructions
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Enrollment with Optum
  6. Support Lines and Contact Numbers
  7. California Appeals and IMR Process
  8. Update Schedule for Resources

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Kesimpta prescriptions OptumRx PA forms OptumRx PA page
Step Therapy Must try preferred DMTs first UHC Commercial PDL 2026 UHC PDL
Formulary Tier Non-preferred specialty (Tier 3+) Member plan documents UHC Provider Portal
Specialty Pharmacy Optum Specialty required Network vendor list UHC Specialty Vendors
Appeals Deadline 180 days from denial Member handbook UHC Provider Portal
IMR Deadline 6 months from appeal decision DMHC guidelines DMHC Filing

Start Here: Verify Your Plan and Find the Right Forms

Before submitting any paperwork, confirm your specific UnitedHealthcare plan's requirements. California members may have different formularies depending on whether they're enrolled in commercial, Medicare Advantage, or employer-sponsored plans.

Step 1: Check Your Plan Type

  1. Log into the UHC member portal using your member ID
  2. Navigate to "Prescription Benefits" to view your formulary
  3. Search for "Kesimpta" or "ofatumumab" to see tier placement and restrictions

Step 2: Verify Current Policy Requirements

UnitedHealthcare's Kesimpta coverage requires:

  • Confirmed relapsing MS diagnosis (ICD-10 code G35) with McDonald criteria documentation
  • Prior DMT failure documentation showing 3-6 months of inadequate response or intolerance to preferred treatments
  • Baseline laboratory work including hepatitis B screening and immunoglobulin levels
  • Neurologist involvement in prescription and ongoing care

Prior Authorization Forms and Requirements

Current PA Form (2024-2025)

UnitedHealthcare processes Kesimpta PA through OptumRx. Download the current form from the OptumRx PA forms page or use the general UHC form.

Key form sections to complete:

  • Patient demographics and insurance information
  • Prescriber details (must be neurologist or have neurologist consultation)
  • Diagnosis with ICD-10 code G35
  • Prior medication trials with specific dates, doses, and outcomes
  • Clinical justification referencing FDA labeling and MS treatment guidelines

Medical Necessity Documentation Checklist

Your neurologist should include:

  • Problem statement: Relapsing MS phenotype with recent activity
  • Prior treatments: Document specific DMTs tried, duration, doses, and reasons for discontinuation
  • Clinical rationale: Why Kesimpta is medically necessary over alternatives
  • Monitoring plan: Laboratory follow-up and safety assessments
Tip: OptumRx eliminated annual reauthorization for Kesimpta in 2024, so a successful initial PA typically provides ongoing coverage without yearly renewals.

Submission Portals and Upload Instructions

Primary Submission Methods

UnitedHealthcare Provider Portal

  • URL: uhcprovider.com
  • Features: Real-time PA submission, status tracking, document upload
  • Support: 24/7 chat available for technical assistance

CoverMyMeds Integration OptumRx partners with CoverMyMeds for streamlined PA submissions. Providers can submit directly through EMR systems or the CoverMyMeds portal.

PreCheck Prior Authorization Launched in October 2024, this automated system provides decisions in under 30 seconds for qualifying requests. Currently expanding to include more specialty medications.

Document Upload Requirements

When submitting through online portals, attach:

  • Complete medical records from neurologist
  • Prior DMT trial documentation
  • Recent MRI reports showing MS lesions
  • Laboratory results (hepatitis B panel, CBC, immunoglobulins)
  • Any relevant hospitalization records for MS relapses

Fax Numbers and Mailing Addresses

OptumRx Prior Authorization

  • Non-urgent PA fax: 1-844-403-1027
  • Urgent/expedited requests: Use online portal for fastest processing
  • Phone support: 1-800-711-4555 for status updates and questions

Cover Sheet Best Practices

Include on all fax submissions:

  • Patient name and date of birth
  • UnitedHealthcare member ID
  • Prescriber name and NPI number
  • "URGENT" notation if time-sensitive
  • Page count and contact information
Note: Fax submissions typically take 72 hours for standard review, while online portal submissions often receive faster processing times.

Specialty Pharmacy Enrollment with Optum

Why Specialty Pharmacy is Required

Kesimpta must be dispensed through UnitedHealthcare's designated specialty pharmacy network. Optum Specialty Pharmacy serves as the primary vendor for ofatumumab.

Enrollment Process

  1. Provider initiation: Prescriber sends prescription to Optum Specialty after PA approval
  2. Patient enrollment: Optum contacts patient within 24-48 hours to complete intake
  3. Benefit verification: Pharmacy confirms coverage, copay amounts, and any remaining requirements
  4. Delivery coordination: Home delivery scheduled based on patient preference

Transfer from Another Pharmacy

If you're currently receiving Kesimpta elsewhere:

  • Contact Optum Specialty at 1-855-720-9297 (verify current number)
  • Provide current pharmacy information for prescription transfer
  • Confirm PA approval carries over to new pharmacy
  • Expect 3-5 business days for transfer completion

Counterforce Health assists patients and providers with navigating complex specialty pharmacy transitions, ensuring continuity of care during insurance changes or pharmacy network updates. Their platform helps identify the specific requirements each specialty pharmacy network requires and streamlines the enrollment process.

Support Lines and Contact Numbers

Member Services

  • General member services: Number on back of insurance card
  • Pharmacy benefits: OptumRx customer service at 1-800-711-4555
  • Prior authorization status: Available through member portal or phone

Provider Support

  • PA assistance: UHC Provider Services (number varies by contract)
  • Peer-to-peer reviews: Request through provider portal within 24 hours of denial
  • Technical support: One Healthcare ID Help Center at 855-819-5909

What to Ask When Calling

For PA status inquiries:

  • Reference number from initial submission
  • Expected decision timeline
  • Any missing documentation requirements
  • Options for expedited review if clinically urgent

For denials:

  • Specific denial reason and policy reference
  • Required documentation for appeal
  • Peer-to-peer review availability
  • Internal appeal submission process

California Appeals and IMR Process

Internal Appeals with UnitedHealthcare

Timeline: Submit within 180 days of denial notice Process:

  1. Use UHC provider portal or written appeal
  2. Include additional clinical documentation
  3. Request peer-to-peer review with UHC medical director
  4. Expect decision within 30 days (3 days for urgent cases)

Independent Medical Review (IMR) Through DMHC

California's robust consumer protection system provides external review through the Department of Managed Health Care.

IMR Eligibility:

  • Denial based on medical necessity
  • Completed UHC internal appeal process
  • Filed within 6 months of appeal decision

IMR Timeline:

Review Type Decision Timeline Implementation
Standard IMR 30 days 5 business days if approved
Expedited IMR 3-7 days Immediate if urgent

How to File IMR:

  1. Visit DMHC complaint page
  2. Complete online application (no fee required)
  3. Upload UHC denial letters and medical records
  4. Include provider statement for expedited review if applicable

IMR Success Rates: California data shows approximately 73% of IMR cases favor the patient, with specialty drug denials frequently overturned when medical necessity is well-documented.

When UnitedHealthcare Must Comply

Recent DMHC enforcement actions, including a $475,000 fine against UnitedHealthcare in December 2025 for appeal violations, demonstrate the state's commitment to ensuring insurers follow IMR decisions. If your IMR is approved, UnitedHealthcare must authorize Kesimpta within 5 business days.

Appeals Playbook: Step-by-Step Process

Level 1: Internal Appeal

Who: Patient or provider When: Within 180 days of denial How: UHC provider portal or written submission Timeline: 30 days for decision (3 days if urgent) Documents needed: Enhanced medical necessity letter, additional clinical evidence

Level 2: Independent Medical Review

Who: Patient (with provider support recommended) When: Within 6 months of internal appeal decision How: DMHC online filing Timeline: 30 days standard, 3-7 days expedited Cost: Free to patient

From our advocates: We've seen many Kesimpta denials overturned at the IMR level when patients include comprehensive documentation of prior DMT failures and a neurologist's letter explaining why alternative treatments aren't suitable. The key is presenting a complete clinical picture that demonstrates medical necessity under the plan's own criteria.

Common Denial Reasons and Solutions

Denial Reason Required Fix Supporting Documents
Inadequate prior DMT documentation Provide detailed trial history with dates, doses, outcomes Neurologist notes, pharmacy records, side effect documentation
Missing MS phenotype confirmation Submit McDonald criteria documentation MRI reports, CSF analysis, clinical assessment
Non-specialist prescriber Add neurologist consultation or co-management Referral letter, specialist evaluation
Step therapy not met Document contraindications or failures of preferred agents Medical records showing adverse events or inadequate response

Update Schedule for Resources

When to Check for Changes

  • Formulary updates: January 1st annually for commercial plans
  • PA form revisions: Quarterly updates possible
  • Policy changes: Monitor UHC provider bulletins
  • California regulations: DMHC updates posted at dmhc.ca.gov

Key Resources to Monitor

Set calendar reminders to verify contact numbers and form versions every six months, as pharmacy benefits frequently change.

Costs and Patient Support Options

Novartis Patient Support

The Kesimpta HCP portal offers:

  • PA form assistance
  • Coverage verification
  • Copay support programs
  • Sample appeals letters

Financial Assistance

  • Manufacturer copay cards: May reduce out-of-pocket costs significantly
  • Foundation grants: Multiple sclerosis organizations offer medication assistance
  • State programs: California residents may qualify for additional support

Counterforce Health's platform helps identify all available financial assistance programs and ensures patients don't miss opportunities for cost reduction while navigating the approval process.

Frequently Asked Questions

How long does UnitedHealthcare PA take for Kesimpta in California? Standard PA decisions are made within 72 hours of complete submission. Urgent requests receive decisions within 24 hours.

What if Kesimpta is non-formulary on my plan? Request a formulary exception through the same PA process, emphasizing medical necessity and prior treatment failures.

Can I request expedited appeal if my MS is worsening? Yes, both UHC internal appeals and California IMR offer expedited processes for urgent medical situations requiring provider documentation.

Does step therapy apply if I tried DMTs in another state? Medical records from any location count toward step therapy requirements if properly documented.

What happens if UnitedHealthcare ignores the IMR decision? DMHC can impose fines and mandate compliance. Recent enforcement actions show California takes IMR violations seriously.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage requirements change frequently. Always verify current policies with UnitedHealthcare and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals and prior authorization, visit www.counterforcehealth.org.

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