By Counterforce Health Team in Koselugo (selumetinib) —

How to Get Koselugo (Selumetinib) Covered by UnitedHealthcare in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Koselugo Approved in Texas

UnitedHealthcare requires prior authorization for Koselugo (selumetinib) in Texas, but approval is often automatic for pediatric patients under 19 with documented NF1 and symptomatic plexiform neurofibromas. Submit the OptumRx PA form with NF1 diagnosis (ICD-10 Q85.01), MRI showing tumors ≥3 cm, symptom documentation, baseline LVEF, and eye exam results. Standard approval takes 30 days; expedited decisions within 72 hours for urgent cases. If denied, Texas law provides internal appeals (180 days to file) and external review through independent organizations.

Table of Contents

  1. Before You Start: Plan Verification
  2. What You Need to Gather
  3. Submitting Your Prior Authorization Request
  4. Following Up on Your Request
  5. Typical Approval Timelines
  6. If More Information is Requested
  7. If Your Request is Denied
  8. Renewal and Reauthorization
  9. Costs and Financial Assistance
  10. Texas Appeals Process
  11. Frequently Asked Questions

Before You Start: Plan Verification

Confirm Your UnitedHealthcare Plan Type

Different UnitedHealthcare plans have varying requirements:

  • Commercial plans: Follow OptumRx formulary guidelines
  • Medicare Advantage: Uses CMS appeal process with 5 levels
  • Medicaid managed care: May have state-specific criteria

Call the number on your insurance card to verify your specific plan and formulary status for Koselugo.

Check Network Status

Ensure your prescribing doctor is in-network with UnitedHealthcare. Koselugo must be filled through OptumRx specialty pharmacy networks - verify this requirement with your plan.

Formulary Tier Confirmation

Koselugo is classified as a specialty medication (SP) requiring prior authorization. The exact tier varies by plan, so check your specific formulary through the UnitedHealthcare member portal or call OptumRx at 1-855-427-4682.

What You Need to Gather

Core Documentation Requirements

Requirement Documentation Needed Where to Get It
NF1 Diagnosis Genetic testing results OR clinical criteria (≥6 café-au-lait spots, family history) Genetics clinic, dermatology records
Plexiform Neurofibroma Evidence MRI or CT showing tumors ≥3 cm Radiology department
Symptom Documentation Clinical notes describing pain, dysfunction, disfigurement Physician progress notes
Inoperability Assessment Surgeon's note explaining surgical risks/impossibility Surgical consultation
Baseline Safety Labs LVEF echocardiogram, ophthalmologic exam Cardiology, ophthalmology
Patient Demographics Age verification (≥2 years), body surface area calculation Medical records

ICD-10 Codes to Include

  • Q85.01: Neurofibromatosis, type 1
  • Document specific symptoms and complications as applicable

Prescriber Requirements

The medication should be prescribed by:

  • Oncologist
  • Neurologist
  • Pediatric specialist familiar with NF1

Submitting Your Prior Authorization Request

Step 1: Access the PA Form

Download the OptumRx Koselugo PA form from the UnitedHealthcare provider portal.

Step 2: Complete Medical Necessity Section

Your doctor should include:

  • Clinical rationale: Why Koselugo is medically necessary
  • Symptom impact: How plexiform neurofibromas affect quality of life
  • Inoperability justification: Why surgical removal isn't possible
  • Monitoring plan: LVEF and eye exam schedule

Step 3: Submit Through Preferred Channel

Electronic submission (fastest): UnitedHealthcare provider portal

  • Often results in automated approval within 29 seconds if criteria are met
  • Request expedited review (72 hours) if urgent

Fax option: Check your specific plan's PA fax number (verify current number with UnitedHealthcare)

Step 4: Specialty Pharmacy Coordination

Ensure your prescription is sent to an in-network OptumRx specialty pharmacy to avoid delays.

Following Up on Your Request

When to Call

  • Day 3: Confirm receipt if no acknowledgment
  • Day 10: Status check for standard requests
  • Day 25: Final follow-up before deadline

Sample Phone Script

"Hello, I'm calling to check the status of a prior authorization request for Koselugo for [patient name], DOB [date]. The request was submitted on [date]. Can you provide an update and reference number?"

Document all interactions with dates, names, and reference numbers.

Typical Approval Timelines

UnitedHealthcare Standard Timelines

Request Type Timeline Notes
Standard PA 30 calendar days Most common for Koselugo
Expedited/Urgent 72 hours If delay would harm health
Medicare Advantage 14 days (standard), 72 hours (expedited) Federal CMS requirements

What Speeds Up Approval

  • Complete documentation on first submission
  • Electronic portal submission
  • Pediatric patients under 19 (often auto-approved)
  • Clear medical necessity justification

If More Information is Requested

UnitedHealthcare may request additional documentation such as:

  • Recent imaging studies
  • Detailed symptom logs
  • Second opinion from specialist
  • Additional safety monitoring results

Response deadline: Typically 14 days from request. Submit promptly to avoid automatic denial.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Fix
Insufficient NF1 documentation Submit genetic testing or comprehensive clinical criteria checklist
Missing symptom evidence Provide detailed clinical notes showing functional impairment
Incomplete safety assessments Submit baseline LVEF and ophthalmologic exam results
Age-related issues Clarify pediatric indication (≥2 years) or adult approval (≥18 years as of Nov 2025)

First-Level Appeal

File within 180 days of denial notice. Include:

  • Original denial letter
  • Additional medical evidence
  • Updated physician letter addressing denial reasons
  • Any new clinical guidelines supporting use

Renewal and Reauthorization

When to Start Renewal Process

Begin 30-60 days before current authorization expires (typically 12-month approvals).

Required Documentation for Renewal

  • Recent MRI showing stable or improved disease
  • Clinical notes documenting continued benefit
  • Updated safety monitoring (LVEF, eye exams)
  • Adherence documentation
  • No evidence of disease progression

Costs and Financial Assistance

Estimated Costs

Koselugo costs approximately $268,677 annually at standard pediatric dosing. Actual costs vary based on:

  • Body surface area
  • Dose reductions
  • Insurance coverage
  • Copay assistance programs

Financial Support Options

  • AstraZeneca patient assistance programs: Check eligibility at manufacturer website
  • Specialty pharmacy copay support: Available through OptumRx network
  • State programs: Texas may have additional support for rare disease medications

Texas Appeals Process

Internal Appeals (Required First Step)

  • Timeline: 180 days from denial to file
  • UnitedHealthcare response: 30 days for standard, 72 hours for expedited
  • Required documents: Denial letter, medical records, physician support letter

External Review (If Internal Appeal Denied)

Texas law provides Independent Review Organization (IRO) review:

  • Timeline: 4 months from final denial to request external review
  • Process: Texas Department of Insurance contracts with independent reviewers
  • Cost: Paid by insurance company
  • Decision: Binding on insurer if overturned

Texas Resources for Help

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926
From Our Advocates: We've seen families succeed by creating a comprehensive "Koselugo packet" that includes side-by-side photos showing tumor growth, detailed symptom diaries, and letters from multiple specialists. This visual and clinical evidence helps reviewers understand the real-world impact when standard documentation alone isn't convincing enough.

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take for Koselugo in Texas? A: Standard requests take up to 30 days, but pediatric cases often get automated approval within hours when complete documentation is submitted electronically.

Q: What if Koselugo isn't on my formulary? A: Even if not listed, medical necessity exceptions are possible. Submit a comprehensive PA request with strong clinical justification.

Q: Can I request an expedited appeal in Texas? A: Yes, if delays would seriously jeopardize your health. Both UnitedHealthcare and Texas external review offer expedited timelines (72 hours and 5 days respectively).

Q: Does step therapy apply to Koselugo? A: Generally no, since Koselugo is the first FDA-approved treatment for NF1 plexiform neurofibromas. However, some plans may require documentation that surgery isn't feasible.

Q: What happens if I move out of Texas during treatment? A: Your UnitedHealthcare coverage typically continues, but appeal rights may change based on your new state's laws. Contact member services immediately.

Q: Are there alternatives if Koselugo is denied? A: Mirdametinib (Gomekli) was approved in November 2025 for both adults and children ≥2 years with NF1 plexiform neurofibromas and may be a formulary alternative.

When Treatment Authorization Gets Complex

Navigating prior authorization for specialty medications like Koselugo can be overwhelming, especially when dealing with denials or complex medical necessity requirements. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create point-by-point rebuttals aligned with each insurer's specific requirements.

The platform pulls the right evidence citations—FDA labeling, peer-reviewed studies, specialty guidelines, and drug compendia—and weaves them into appeals with required clinical facts like diagnosis codes, prior treatment failures, contraindications, and dosing details. For complex cases involving multiple specialists and extensive documentation requirements, having expert support can make the difference between approval and prolonged delays.

Checklist: Before You Submit

Print this checklist and verify each item:

Documentation Complete:

  • NF1 diagnosis confirmed (genetic test or clinical criteria)
  • MRI/CT showing plexiform neurofibromas ≥3 cm
  • Clinical notes documenting symptoms and functional impact
  • Surgical consultation confirming inoperability
  • Baseline LVEF echocardiogram results
  • Ophthalmologic examination results
  • Patient age verification (≥2 years)
  • Body surface area calculation for dosing

Submission Ready:

  • PA form completely filled out by prescriber
  • In-network provider confirmed
  • OptumRx specialty pharmacy identified
  • Electronic submission preferred method chosen
  • Reference numbers documented for follow-up

Support Ready:

  • Contact information for all specialists involved
  • Insurance card and member ID available
  • Calendar reminders set for follow-up calls
  • Appeal timeline documented (180 days from any denial)

Medical Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for coverage determinations. Coverage policies and requirements may change.

Sources and Further Reading

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