By Counterforce Health Team in Kesimpta (ofatumumab) —

How to Get Kesimpta (Ofatumumab) Covered by UnitedHealthcare in Pennsylvania: Prior Authorization, Appeals, and Cost-Saving Strategies

Quick Answer: Getting Kesimpta Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Kesimpta (ofatumumab) through OptumRx, typically mandating step therapy with other disease-modifying therapies first. Your neurologist submits the PA via UHC Provider Portal with MS diagnosis (ICD-10 G35), prior DMT failures, and baseline labs. Standard decisions take 72 hours; expedited reviews 24 hours. If denied, you have 180 days for internal appeals, followed by Pennsylvania's external review program where 53% of denials are overturned. First step today: Call UnitedHealthcare member services (number on your ID card) to verify Kesimpta's formulary status and confirm OptumRx handles your pharmacy benefits.

Table of Contents

What Drives Kesimpta Costs with UnitedHealthcare

Understanding your UnitedHealthcare plan's benefit design helps predict Kesimpta costs. As a specialty biologic, Kesimpta typically falls on higher formulary tiers with significant cost-sharing.

Key Cost Factors:

  • Formulary tier placement: Kesimpta is classified as a specialty medication (SP) with "Multiple copay" (MC) indicator, meaning costs vary by specific benefit plan
  • Prior authorization requirements: OptumRx manages PA for UnitedHealthcare, adding approval steps before coverage
  • Step therapy mandates: Most plans require trials of preferred DMTs before approving Kesimpta
  • Specialty pharmacy requirements: Must use OptumRx specialty pharmacy network
Note: UnitedHealthcare eliminated reauthorization requirements for Kesimpta in 2024, so initial approval covers ongoing use without annual renewals.

Benefit Investigation: What to Ask

Before starting the approval process, gather essential benefit information from UnitedHealthcare.

Call Member Services (number on your ID card) and ask:

  1. "Is Kesimpta (ofatumumab) covered on my formulary? What tier?"
  2. "Does OptumRx handle my specialty pharmacy benefits?"
  3. "What's my specialty drug copay or coinsurance?"
  4. "Is prior authorization required? Any step therapy requirements?"
  5. "What's my annual out-of-pocket maximum for specialty drugs?"

Document this information:

  • Plan type (commercial, Medicare Advantage, employer-sponsored)
  • Formulary tier and cost-sharing
  • Deductible remaining
  • Prior authorization requirements
  • Specialty pharmacy network restrictions

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing plan policies and crafting point-by-point rebuttals aligned to each insurer's specific rules.

Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Kesimpta across all relevant plans, with specific clinical criteria that must be met.

Coverage Requirements Table

Requirement Details Documentation Needed
Prior Authorization Mandatory; submit via UHC Provider Portal or call 866-889-8054 MS diagnosis (ICD-10 G35, McDonald criteria), prior DMT history, baseline labs
Step Therapy Trial preferred DMTs first unless contraindicated Records of prior DMT outcomes, MRI showing activity, specialist notes
Diagnosis Relapsing forms of MS (CIS, RRMS, active SPMS) Neurologist notes, ICD-10 G35
Specialty Pharmacy OptumRx required Provider credentials, safety screening (HBV, vaccinations)
Timeline 72 hours standard; 24 hours expedited Complete documentation speeds approval

Step-by-Step PA Process

  1. Verify Coverage (Same day): Check UHC member portal or call member services
  2. Gather Documentation (1-3 days): MS history, prior DMT failures, labs, MRI results, neurologist notes
  3. Submit PA (1 business day): Provider uses UHC Provider Portal with all supporting documents
  4. Track Status: Monitor portal or call OptumRx PA team at 1-800-711-4555
  5. Follow Up: If denied, request peer-to-peer review within 24 hours
Clinician Corner: Medical necessity letters should document specific MS phenotype, prior DMT failures with dates and reasons (efficacy, tolerability, adherence), contraindications to preferred therapies, and baseline safety labs including hepatitis B screening.

Assistance Options and Copay Programs

Several programs can reduce Kesimpta's out-of-pocket costs for eligible patients with UnitedHealthcare coverage.

Novartis Copay Assistance (Alongside KESIMPTA Program)

Eligibility Requirements:

  • Commercial insurance coverage (not Medicare, Medicaid, TRICARE, or other government programs)
  • U.S. residency
  • Insurance covers Kesimpta (even with prior authorization)

Benefits:

  • Up to $18,000 annual funding
  • Patient pays $0 copay until assistance exhausted
  • Reduced to ≤$9,000 if subject to copay maximizer programs

How to Enroll:

  1. Visit start.kesimpta.com (patient/guardian enrollment only)
  2. Get $0 copay card for pharmacy use
  3. Call Novartis Patient Support at 1-855-787-8476 for benefits verification

Additional Support Programs

Novartis Patient Assistance Program (PAP):

  • Free medication for income-qualified patients
  • Up to 12 months coverage with annual re-enrollment
  • Apply at pap.novartis.com

Bridge Program:

  • Free Kesimpta up to 12 months for commercial patients denied via prior authorization
  • Managed through Novartis Patient Support

Appeals Process in Pennsylvania

Pennsylvania offers robust appeal rights, including a state-run external review program with high success rates for overturning denials.

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial notice Process:

  1. Submit via UHC Provider Portal or member portal
  2. Request peer-to-peer review with UHC medical director (schedule within 24 hours)
  3. Include enhanced documentation addressing specific denial reasons
  4. Standard review: 30 days; expedited: 72 hours for urgent cases

Pennsylvania External Review Program

After exhausting internal appeals, Pennsylvania's Independent External Review Program provides an independent assessment.

Key Features:

  • Success rate: 53% of denials overturned in first six months (2024 data)
  • Timeline: 45 days for standard review; 72 hours for expedited
  • Binding decisions: If overturned, UnitedHealthcare must provide coverage immediately
  • Cost: Free to patients

Eligibility:

  • Fully insured commercial plans (not self-funded employer plans)
  • Final adverse determination from internal appeal
  • Medical necessity or experimental treatment denials

How to Submit:

  1. Visit Pennsylvania Insurance Department External Review Portal
  2. Submit within 4 months of final internal denial
  3. Include denial letters, medical records, and drug-specific information
  4. Submit additional supporting information within 15 days of IRO assignment
From Our Advocates: We've seen Pennsylvania's external review program particularly effective for specialty drugs like Kesimpta when the initial denial cited "experimental" status despite FDA approval for relapsing MS. Strong neurologist support letters emphasizing the drug's first-line status often tip the scales in the patient's favor.

Pharmacy Choice and Coordination

UnitedHealthcare requires Kesimpta dispensing through OptumRx specialty pharmacy network, limiting patient choice but ensuring proper handling.

OptumRx Specialty Pharmacy Process

After PA Approval:

  1. OptumRx contacts patient to coordinate first shipment
  2. Medication ships monthly with temperature monitoring
  3. Clinical pharmacists provide injection training and ongoing support
  4. Automatic refill coordination with prescriber

Patient Responsibilities:

  • Maintain current contact information
  • Coordinate delivery timing
  • Report side effects to OptumRx clinical team
  • Ensure refrigeration upon delivery

Coordination Tips

  • Provider communication: Ensure prescriber coordinates with OptumRx for seamless transitions
  • Backup planning: Know OptumRx customer service number (on medication packaging) for delivery issues
  • Travel considerations: OptumRx can coordinate shipments to temporary addresses with advance notice

Renewal and Annual Changes

While Kesimpta no longer requires annual reauthorization, benefit changes can affect coverage and costs.

Annual Open Enrollment Planning

What Can Change:

  • Formulary tier placement
  • Prior authorization criteria
  • Specialty pharmacy network
  • Copay assistance program terms
  • Out-of-pocket maximums

Preparation Steps:

  1. Review new formulary documents (available 60 days before plan year)
  2. Verify OptumRx remains specialty pharmacy provider
  3. Re-enroll in Novartis copay assistance if needed
  4. Update provider on any benefit changes

Conversation Scripts

Patient Script for UnitedHealthcare Member Services

"Hi, I need to verify coverage for Kesimpta, spelled K-E-S-I-M-P-T-A, for multiple sclerosis. Can you tell me: Is it covered on my formulary and what tier? Does it require prior authorization? What's my specialty drug copay? Does OptumRx handle specialty pharmacy for my plan?"

Provider Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for Kesimpta denial. The patient has relapsing MS with documented failure of [specific DMT] due to [efficacy/tolerability]. Kesimpta is FDA-approved first-line therapy, and step therapy requirements shouldn't apply given [contraindication/failure]. I have complete documentation including MRI progression and safety labs."

Clinic Staff Script for PA Status

"I'm checking prior authorization status for patient [name], DOB [date], member ID [number] for Kesimpta. The PA was submitted [date] through the provider portal. Can you provide current status and expected decision timeline?"

FAQ

How long does UnitedHealthcare PA take for Kesimpta in Pennsylvania? Standard decisions within 72 hours; expedited reviews within 24 hours. OptumRx automation may speed select approvals to 30 seconds.

What if Kesimpta is non-formulary on my UnitedHealthcare plan? Non-formulary medications can still be covered through medical exception appeals with strong clinical justification and documentation of medical necessity.

Can I request expedited appeals in Pennsylvania? Yes, for urgent cases where delays could jeopardize health. Both UnitedHealthcare internal appeals and Pennsylvania external review offer expedited timelines.

Does step therapy apply if I've tried DMTs outside Pennsylvania? Yes, documented DMT trials from any location count toward step therapy requirements if properly documented in medical records.

What happens if OptumRx denies specialty pharmacy dispensing? This is rare but can be appealed separately from coverage denials. Contact UnitedHealthcare member services for specialty pharmacy network exceptions.

How does Pennsylvania's external review compare to other states? Pennsylvania's program is newer (2024) but shows higher success rates (53%) than many state programs, with faster timelines and comprehensive coverage of denial types.

Counterforce Health helps patients and providers navigate these complex appeal processes by analyzing denial letters and plan policies to craft targeted rebuttals that address specific payer requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always verify current requirements with UnitedHealthcare and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals, contact the Pennsylvania Insurance Department's consumer services or consider working with specialized advocacy services.

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