By Counterforce Health Team in Ofev (nintedanib) —

How to Get Ofev (nintedanib) Covered by UnitedHealthcare in Ohio: Prior Authorization Guide & Appeals Process

Quick Answer: Getting Ofev Covered by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Ofev (nintedanib) through OptumRx, with approval typically granted within 72 hours when complete documentation is submitted. Key requirements include: pulmonologist prescription, confirmed IPF/SSc-ILD diagnosis with HRCT evidence, pulmonary function test decline, and ICD-10 coding. Submit via the UnitedHealthcare Provider Portal or call 888-397-8129. If denied, Ohio residents have 180 days for external review through the Ohio Department of Insurance after exhausting internal appeals.

First step today: Verify your plan's formulary status and gather HRCT reports, PFT results, and specialist documentation before your pulmonologist submits the prior authorization request.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Mandatory for all plans UnitedHealthcare Provider Portal 72 hours standard, 24 hours urgent
Pulmonologist Prescription Board-certified specialist required Provider credentials verification At submission
HRCT Evidence High-resolution CT showing fibrosis Radiology report (within 6-12 months) Before PA submission
PFT Decline ≥10% FVC decline over 24 months OR 5-10% with symptoms Pulmonary function test results Before PA submission
Specialty Pharmacy Optum Specialty Pharmacy required 1-855-427-4682 After PA approval
Annual Reauthorization Positive clinical response documentation Provider portal 12 months from approval

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan Coverage (Patient/Clinic Staff)

Check your specific UnitedHealthcare plan's formulary through the member portal or call member services. Ofev may be on different tiers depending on your plan type (commercial, Medicare Advantage, or Medicaid).

2. Gather Required Documentation (Clinic Staff)

Essential documents before submission:

  • HRCT chest scan report showing fibrosis pattern
  • Pulmonary function tests demonstrating decline
  • Complete medical history including prior treatments
  • ICD-10 diagnosis code (J84.112 for IPF)
  • Prescriber credentials verification

3. Submit Prior Authorization (Pulmonologist)

Primary method: UnitedHealthcare Provider Portal Alternative: Call 888-397-8129 Timeline: Submit 7-14 days before intended treatment start

Tip: UnitedHealthcare's automated approval system may approve requests in under 30 seconds if all electronic criteria are met.

4. Coordinate with Optum Specialty Pharmacy (Patient/Clinic)

Once approved, your prescription must be transferred to Optum Specialty Pharmacy (1-855-427-4682) for fulfillment and home delivery.

5. Monitor and Prepare for Reauthorization (Patient/Clinic)

Track your approval status through the provider portal and prepare annual reauthorization documentation showing positive clinical response.

Prior Authorization Forms and Submission

Required Clinical Information

Your pulmonologist must submit documentation including:

Diagnosis Confirmation:

  • ICD-10 code J84.112 (Idiopathic pulmonary fibrosis) or appropriate code for SSc-ILD
  • Exclusion of other known causes of interstitial lung disease
  • HRCT report confirming fibrosis pattern

Disease Progression Evidence:

  • Pulmonary function test results showing FVC decline ≥10% over 24 months
  • OR FVC decline 5-10% with worsening symptoms
  • Baseline and follow-up PFT comparison

Treatment History:

  • Documentation of contraindications to alternative therapies if applicable
  • Prior treatment attempts and outcomes
  • Current symptom severity and functional status

Submission Methods

Method Contact Response Time Notes
Provider Portal uhcprovider.com 72 hours standard Preferred method; automated approval possible
Phone 888-397-8129 24 hours urgent For expedited requests
Fax 1-866-434-5523 72 hours standard OptumRx prior authorization fax

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing specialist evaluation Submit pulmonologist consultation note Board-certified pulmonologist assessment with credentials
Insufficient progression evidence Provide comparative PFT data Serial PFTs showing ≥10% FVC decline or 5-10% with symptoms
Lack of HRCT confirmation Submit radiology report High-resolution CT chest showing UIP/fibrotic pattern
Step therapy not met Document pirfenidone failure/intolerance Medical records showing adverse effects or contraindications
Incorrect diagnosis coding Verify ICD-10 accuracy J84.112 (IPF), M34.81 (SSc-ILD), or appropriate code

Appeals Process in Ohio

Internal Appeals (Required First Step)

Timeline: File within 21 calendar days of denial Method: UnitedHealthcare Provider Portal (electronic submission required starting June 2, 2025) Response time: 5-10 business days standard, 72 hours for urgent appeals

Required for urgent appeals:

  • Physician certification that delay would seriously jeopardize health
  • Clinical documentation supporting urgency

External Review (Ohio Department of Insurance)

Eligibility: After exhausting internal appeals for medical necessity denials Timeline: Must file within 180 days of final internal denial Contact: Ohio Department of Insurance at 1-800-686-1526 Process: Independent medical review by certified experts Decision timeline: 30 days standard, 72 hours expedited

Note: Ohio law allows the Department of Insurance to independently determine external review eligibility, even if UnitedHealthcare initially disputes it.

Clinician Corner: Medical Necessity Letter Essentials

When appealing a denial, include these elements in your medical necessity letter:

Clinical Rationale:

  • Patient's specific diagnosis and disease progression
  • Why Ofev is medically necessary for this patient
  • Expected clinical benefits and monitoring plan

Evidence Base:

  • FDA labeling for approved indications
  • Clinical trial data (SENSCIS for SSc-ILD, INPULSIS for IPF)
  • Professional society guidelines (ATS/ERS/JRS/ALAT IPF guidelines)

Treatment History:

  • Prior therapies attempted and outcomes
  • Contraindications to alternative treatments
  • Current functional status and quality of life impact

Specialty Pharmacy Requirements

UnitedHealthcare requires Ofev to be dispensed through its specialty pharmacy network, primarily Optum Specialty Pharmacy.

Enrollment Process

  1. Prescription Transfer: Your pulmonologist sends the prescription directly to Optum Specialty Pharmacy
  2. Insurance Verification: Pharmacy verifies coverage and processes prior authorization if not already completed
  3. Patient Contact: Optum contacts you for delivery coordination and medication counseling
  4. Home Delivery: Monthly shipments with clinical support and refill coordination

Contact Information:

  • Optum Specialty Pharmacy: 1-855-427-4682
  • Services: 24/7 pharmacist consultation, medication counseling, side effect management

Cost Assistance Programs

Manufacturer Support

Boehringer Ingelheim CareConnect4Me

  • Copay assistance for eligible patients
  • Prior authorization support
  • Appeals assistance
  • Contact: ofev.com or 1-800-542-6257

Additional Resources

BI Cares Foundation

  • Financial assistance for uninsured/underinsured patients
  • Income-based eligibility requirements
  • Application through healthcare provider

When to Contact Ohio Regulators

Ohio Department of Insurance

Contact: 1-800-686-1526 Services: External review coordination, consumer assistance, regulatory complaints Website: insurance.ohio.gov

File a complaint when:

  • UnitedHealthcare improperly denies external review eligibility
  • Appeals process violations occur
  • Unreasonable delays in processing

Additional Ohio Resources

UHCAN Ohio (Universal Health Care Action Network)

  • Consumer advocacy and assistance
  • Appeals support and guidance

OSHIIP (Ohio Senior Health Insurance Information Program)

  • Medicare-specific assistance for seniors
  • Coverage counseling and appeals support

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Ofev in Ohio? Standard requests receive responses within 72 hours, while urgent requests are processed within 24 hours. Automated approval may occur in under 30 seconds if all criteria are met electronically.

What if Ofev is not on my UnitedHealthcare formulary? You can request a formulary exception through the prior authorization process. Your pulmonologist must demonstrate medical necessity and provide clinical justification for why formulary alternatives are inappropriate.

Can I get an expedited appeal if my condition is worsening? Yes, if your physician certifies that a delay would seriously jeopardize your health, you can request an expedited appeal with a 72-hour response requirement.

Does step therapy apply if I've tried pirfenidone in another state? Medical records documenting prior pirfenidone treatment, failure, or intolerance from any location should satisfy step therapy requirements. Ensure your pulmonologist includes this documentation in the prior authorization.

What happens if my appeal is denied? After exhausting internal appeals, you have 180 days to request external review through the Ohio Department of Insurance. This independent medical review is binding on UnitedHealthcare if overturned.

How much does Ofev cost without insurance in Ohio? Cash prices typically range from $13,000-$15,000 for a 30-day supply (60 capsules). Manufacturer assistance programs and specialty pharmacy support can significantly reduce out-of-pocket costs.

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create comprehensive appeals that address specific payer requirements and include the right clinical evidence. Learn more about our prior authorization support services.

Sources & Further Reading

This article is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Coverage policies may vary by plan and change over time. Verify current requirements with UnitedHealthcare and consult the Ohio Department of Insurance for the most up-to-date appeals information.

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