By Counterforce Health Team in Orladeyo (berotralstat) —

How to Get Orladeyo (berotralstat) Covered by UnitedHealthcare in Washington: Complete Guide to Forms, Appeals, and Timelines

Answer Box: Getting Orladeyo Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for Orladeyo (berotralstat) with documented HAE diagnosis, step therapy completion, and specialty pharmacy dispensing. Submit PA via UnitedHealthcare Provider Portal or fax to 1-844-403-1027 within 24-72 hours for electronic requests. If denied, file internal appeals within 180 days, then external review through Washington's Independent Review Organization (IRO) process within 60 days.

Start today: Verify coverage through member services, gather HAE labs (C1-INH levels, C4), document prior prophylaxis failures, and contact Orladeyo Empower Patient Services at orladeyo.com for enrollment support.

Table of Contents

  1. Verify Your Plan and Find Forms
  2. Required Prior Authorization Forms
  3. Submission Portals and Electronic Options
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Enrollment
  6. Support Lines and Contact Information
  7. Washington State Appeals and External Review
  8. Coverage Requirements at a Glance
  9. Common Denial Reasons and Solutions
  10. Costs and Patient Assistance

Verify Your Plan and Find Forms

Before starting your Orladeyo prior authorization, confirm your UnitedHealthcare plan type and current policy. Washington residents may have commercial, Medicare Advantage, or Medicaid (Apple Health) coverage through UnitedHealthcare, each with different requirements.

First steps:

  • Call the member services number on your insurance card
  • Ask specifically: "Does my plan cover Orladeyo for hereditary angioedema prophylaxis?"
  • Request: "What specialty pharmacies are in-network for Orladeyo in Washington?"
  • Verify: Your plan's prior authorization requirements and any step therapy mandates
Note: Some UnitedHealthcare plans list Orladeyo as "typically excluded from coverage" unless required by law or specific benefit design. Washington's strong external review process can help override such exclusions when medically necessary.

Required Prior Authorization Forms

UnitedHealthcare uses two main pathways for Orladeyo coverage, depending on your specific plan:

Standard Prior Authorization Form

  • Form name: OptumRx General Prior Authorization Request
  • Download: CoverMyMeds OptumRx forms
  • Required sections: Diagnosis (ICD-10 D84.1), prior therapies, attack frequency, prescriber attestation

Medical Necessity Program (More Restrictive)

  • Form name: Orladeyo Medical Necessity Request
  • Requirements: Documented failure of C1-INH therapy AND one other prophylactic agent
  • Coverage duration: 12 months if approved
  • Download: Available through UnitedHealthcare Provider Portal

Key documentation to include:

  • HAE diagnosis confirmation (C1-INH antigenic/functional levels, C4 levels)
  • Attack diary showing ≥2 attacks per month requiring prophylaxis
  • Prior therapy trials with dates, duration, and failure reasons
  • Specialist consultation notes (allergist/immunologist preferred)

Submission Portals and Electronic Options

Electronic submission provides the fastest processing times (24-72 hours for complete requests):

UnitedHealthcare Provider Portal

  • URL: uhcprovider.com
  • Access: Requires One Healthcare ID registration
  • Features: Real-time PA status, document upload, appeal submission
  • Tool: Use "Prior Authorization and Notification" section

CoverMyMeds Integration

  • Platform: Electronic PA submission directly to OptumRx
  • Benefits: Automated form population, real-time decision tracking
  • Access: Through EMR integration or direct portal login

Member Portal Options

  • Patients can check PA status through UnitedHealthcare member portal
  • Upload supporting documents via secure messaging
  • Track appeal status and deadlines

Fax and Mail Submission Details

Primary Fax Numbers

  • Non-urgent requests: 1-844-403-1027
  • Expedited/urgent cases: Call 1-800-711-4555 first, then fax

Fax Cover Sheet Requirements

  • Member ID and date of birth
  • Prescriber NPI and contact information
  • "ORLADEYO PRIOR AUTHORIZATION" in subject line
  • Page count and confirmation request

Mailing Address

Check current mailing address through UnitedHealthcare Provider Portal, as addresses change periodically for security and processing efficiency.

Specialty Pharmacy Enrollment

Orladeyo requires dispensing through UnitedHealthcare's contracted specialty pharmacy network. Most plans mandate this for cost management and clinical monitoring.

Enrollment Steps

  1. Contact Orladeyo Empower Patient Services
    • Website: orladeyo.com/empower-patient-services
    • Services: Insurance verification, PA support, pharmacy coordination
    • Timeline: First shipment typically within 1 week of prescription receipt
  2. Verify In-Network Specialty Pharmacy
    • Call UnitedHealthcare to confirm approved pharmacies in Washington
    • Common options: Optum Specialty Pharmacy, contracted regional specialty pharmacies
    • Confirm home delivery vs. local pickup options
  3. Prescription Transfer Process
    • Current pharmacy transfers directly to UnitedHealthcare-approved specialty pharmacy
    • Include remaining refills, PA approval dates, and dosing instructions
    • Empower Patient Services can coordinate transfers to minimize gaps

Support Lines and Contact Information

Member Services

  • General inquiries: Number on insurance card
  • Ask about: Coverage verification, formulary status, appeal deadlines
  • Best times: Early morning or late afternoon for shorter hold times

Provider Services

  • Prior authorization support: 1-800-711-4555
  • Expedited reviews: Same number, specify urgency
  • Portal technical support: 855-819-5909

Orladeyo Manufacturer Support

  • Empower Patient Services: Available through orladeyo.com
  • Services: PA assistance, appeals support, Quick Start programs
  • Benefit: Coordinates with UnitedHealthcare on patient's behalf

Washington State Appeals and External Review

Washington provides robust consumer protections for insurance denials, making it one of the most favorable states for overturning coverage denials.

Internal Appeals Process

  • Deadline: 180 days from denial notice
  • Levels: Typically 1-2 internal review levels
  • Submission: UnitedHealthcare Provider Portal, fax, or mail
  • Timeline: Standard reviews within 30 days, expedited within 72 hours

External Review (IRO Process)

  • Eligibility: After exhausting internal appeals
  • Deadline: 60 days from final internal denial
  • Process: Submit request to UnitedHealthcare, who assigns certified Independent Review Organization
  • Timeline: 20 days for standard review, 72 hours for expedited
  • Authority: IRO decision is binding on UnitedHealthcare

Washington Office of Insurance Commissioner

  • Consumer helpline: Available through insurance.wa.gov
  • Services: Appeal guidance, complaint filing, template letters
  • Resources: "How to appeal a health care insurance decision" guide with sample external review letter
From our advocates: We've seen Washington patients successfully overturn Orladeyo denials by emphasizing the oral administration advantage for patients who cannot self-inject other HAE prophylaxis options. Document any injection-related issues, travel constraints, or quality-of-life factors that make oral therapy medically necessary.

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
HAE Diagnosis Type I/II (C1-INH deficiency) or Type III (normal C1-INH with genetic variants) Lab results, genetic testing if applicable UHC Policy
Age Restriction ≥12 years Date of birth verification UHC PA Form
Step Therapy Trial of two preferred prophylaxis agents Prior therapy documentation with dates and outcomes UHC Policy
Prophylaxis Only Not for acute attack treatment Prescriber attestation of prophylactic use UHC PA Form
Attack Frequency ≥2 attacks per month typical threshold Attack diary or clinical documentation UHC Policy
Specialty Pharmacy Dispensing through approved network Enrollment with contracted pharmacy UHC Member Services

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient HAE documentation Submit complete lab workup C1-INH levels, C4, functional assays, genetic testing results
Step therapy not completed Document prior prophylaxis failures Trial dates, duration, specific reasons for discontinuation
Age under 12 years Confirm patient age Birth certificate or medical record verification
Requested for acute treatment Clarify prophylactic indication Prescriber letter emphasizing prevention, not acute use
Lack of specialist involvement Obtain specialist consultation Allergist/immunologist evaluation and recommendation
Insufficient attack frequency Document attack burden Detailed attack diary, emergency department visits, impact on daily life

Costs and Patient Assistance

Manufacturer Support

  • Orladeyo Empower Patient Services: Copay assistance and patient support programs
  • Eligibility: Typically for commercially insured patients
  • Savings: Can significantly reduce out-of-pocket costs

Washington State Resources

  • Apple Health (Medicaid): May cover Orladeyo with prior authorization
  • Washington Healthplanfinder: Marketplace plans with varying formulary coverage
  • Patient advocate organizations: HAEA (Hereditary Angioedema Association) provides resources

Foundation Assistance

  • Rare disease foundations: Often provide grants for expensive medications
  • Eligibility: Based on income and insurance coverage gaps

At Counterforce Health, we specialize in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed responses. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes for rare disease medications like Orladeyo.

When Coverage Is Still Denied

If UnitedHealthcare maintains denial after internal appeals, Washington residents have strong external review rights. The state's Independent Review Organization process has successfully overturned many rare disease medication denials when medical necessity is clearly documented.

Consider working with Counterforce Health for complex appeals that require detailed policy analysis and clinical evidence compilation. Our platform identifies specific denial reasons and crafts targeted rebuttals aligned with UnitedHealthcare's own coverage criteria.

Timeline for Appeals in Washington

  • Internal Appeal: File within 180 days of denial
  • External Review: Request within 60 days of final internal denial
  • IRO Decision: Binding determination within 20 days (72 hours if expedited)
  • Implementation: UnitedHealthcare must comply immediately with favorable IRO decisions

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. Coverage policies and requirements may change; verify current information with UnitedHealthcare and Washington state regulators.

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