By Counterforce Health Team in Pemazyre (pemigatinib) —

How to Get Pemazyre (Pemigatinib) Covered by UnitedHealthcare in Georgia: Appeals Guide and External Review Process

Quick Answer: Getting Pemazyre Covered by UnitedHealthcare in Georgia

Yes, you can get Pemazyre (pemigatinib) covered by UnitedHealthcare in Georgia, but it requires prior authorization and molecular testing proof. The fastest path: 1) Ensure your doctor has documented FGFR2 fusion/rearrangement with lab reports, 2) Submit a complete prior authorization with ophthalmic monitoring plan through UnitedHealthcare's provider portal, 3) If denied, file an internal appeal within 180 days, then request external review through Georgia DOI within 60 days. Start by calling UnitedHealthcare Provider Services at 1-877-842-3210 to confirm current requirements for your specific plan.

Table of Contents

Understanding Your Denial Letter

When UnitedHealthcare denies coverage for Pemazyre, the denial letter will include specific reason codes. Common reasons include:

  • Missing FGFR alteration documentation - The most frequent cause
  • No ophthalmic monitoring plan - Required due to eye toxicity risks
  • Step therapy requirements - May need to try other treatments first
  • Quantity limits exceeded - Standard dosing must be justified
  • Off-label use without sufficient evidence - Requires additional documentation
Tip: Keep the original denial letter and note the date received. You have 180 days to file an internal appeal with UnitedHealthcare.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans UHC Provider Portal UHC PA Requirements
FGFR Testing Molecular pathology report mandatory Lab/pathology report FDA Label Requirements
Ophthalmic Plan Eye monitoring every 2 months initially Provider documentation FDA Safety Info
Step Therapy May require trying alternatives first Plan formulary OptumRx Policy
Internal Appeal 180 days from denial date UHC member portal Georgia Insurance Law
External Review 60 days from final internal denial Georgia DOI GA DOI Rules

Step-by-Step: Fastest Path to Approval

1. Confirm FGFR Alteration Status

Who: Your oncologist
What: Order comprehensive molecular profiling if not done
Timeline: 1-2 weeks for results
Submit: Include pathology report with PA request

2. Establish Ophthalmic Monitoring Plan

Who: Your care team
What: Schedule baseline eye exam with OCT imaging
Timeline: Before treatment starts
Document: Monitoring schedule every 2 months for 6 months, then every 3 months

3. Submit Prior Authorization

Who: Prescribing physician's office
What: Complete PA through UHC Provider Portal
Timeline: 3-5 business days for decision
Include: All supporting documentation

4. Request Peer-to-Peer if Denied

Who: Your doctor
What: Call Provider Services at 1-877-842-3210
Timeline: Within 5-7 days of denial
Prepare: Clinical evidence and guideline references

5. File Internal Appeal

Who: You or your doctor
What: Submit written appeal with additional evidence
Timeline: Within 180 days of denial
Submit: Via UHC member portal or certified mail

6. Request External Review (if needed)

Who: You (the patient)
What: Contact Georgia DOI Consumer Services
Timeline: Within 60 days of final internal denial
Call: 1-800-656-2298

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
No FGFR alteration documented Submit molecular pathology report Lab report showing FGFR2 fusion/rearrangement
Missing ophthalmic monitoring Provide detailed eye monitoring plan Ophthalmology consultation note
Step therapy not met Request exception with contraindications Prior therapy failure documentation
Off-label use Submit clinical evidence NCCN guidelines, peer-reviewed studies
Quantity limit exceeded Justify dosing based on FDA label Prescriber attestation letter

Medical Necessity Letter Checklist

Essential Elements for Your Doctor to Include:

Patient Information:

  • Full name, DOB, UnitedHealthcare member ID
  • Specific diagnosis with ICD-10 code
  • Stage and histologic subtype of cancer

FGFR Documentation:

  • Laboratory report confirming FGFR2 fusion or rearrangement
  • Testing methodology (e.g., next-generation sequencing)
  • Attach complete molecular pathology report

Treatment History:

  • Prior therapies attempted with dates
  • Response to treatment and reasons for discontinuation
  • Documentation of treatment failure or intolerance

Clinical Justification:

  • FDA approval for this specific indication
  • Reference to NCCN Guidelines support
  • Expected treatment duration and monitoring plan

Safety Monitoring:

  • Comprehensive ophthalmic monitoring schedule
  • Plan for managing drug interactions (CYP3A4)
  • Phosphate level monitoring protocol
Clinician Note: Attach all supporting documentation including pathology reports, prior treatment records, and the detailed ophthalmic monitoring plan. Reference the FDA label for dosing and safety requirements.

Appeals Process in Georgia

Internal Appeals with UnitedHealthcare

First Level Internal Appeal:

  • Deadline: 180 days from denial date
  • How to file: UHC member portal or certified mail
  • Timeline: 30 days for standard review, 72 hours for urgent
  • Required: Written request with additional clinical evidence

Second Level Internal Appeal:

  • Automatic: If first level upheld
  • Timeline: Additional 30 days for decision
  • Outcome: Final internal determination

Expedited Appeals for Urgent Cases

If delaying treatment could seriously harm your health:

  • Request: Expedited review when filing appeal
  • Timeline: 72 hours for decision
  • Eligibility: Time-sensitive medical conditions
  • Contact: Provider Services at 1-877-842-3210

External Review Through Georgia DOI

If UnitedHealthcare upholds their denial after internal appeals, Georgia law gives you the right to an independent external review.

How to Request External Review

Contact Information:

  • Phone: Georgia DOI Consumer Services at 1-800-656-2298
  • Website: oci.georgia.gov
  • Forms: Available online or by calling the hotline

Requirements:

  • Must complete all internal appeals first
  • File within 60 days of final internal denial
  • No cost to you for the review

Timeline:

  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases
  • Decision: Legally binding on UnitedHealthcare

What to Include with External Review Request

  • Copy of all denial letters from UnitedHealthcare
  • Medical records supporting necessity
  • Doctor's letter explaining why Pemazyre is needed
  • Any additional clinical evidence
Important: Georgia's external review decision is final and legally binding. If approved, UnitedHealthcare must cover the treatment.

Scripts and Templates

Patient Script for Calling UnitedHealthcare

"Hi, I'm calling about a prior authorization denial for Pemazyre. My member ID is [ID number]. I received a denial on [date] and want to understand the specific requirements for approval. Can you tell me exactly what documentation is needed and connect me with someone who can schedule a peer-to-peer review for my doctor?"

Medical Necessity Letter Template Opening

"This letter serves to request coverage for Pemazyre (pemigatinib) for [patient name], who has [specific diagnosis] with confirmed FGFR2 fusion/rearrangement. The patient meets FDA-approved indication criteria and NCCN guideline recommendations. Comprehensive molecular testing confirms the actionable FGFR alteration (see attached pathology report)."

Costs and Financial Assistance

Manufacturer Support Programs

Incyte Cares Patient Assistance:

  • Website: hcp.incytecares.com
  • Eligibility: Based on income and insurance status
  • Coverage: May provide free medication for qualifying patients

Copay Assistance:

  • Available for commercially insured patients
  • May reduce out-of-pocket costs significantly
  • Apply through manufacturer website or pharmacy

Additional Financial Resources

  • CancerCare Financial Assistance: Limited grants available
  • Patient Advocate Foundation: Copay relief programs
  • Georgia Cancer Coalition: State-specific resources

Counterforce Health helps patients navigate these complex approval processes by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and creates customized appeals that address each payer's specific requirements.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Pemazyre in Georgia? Standard PA decisions take 3-5 business days. Urgent requests may be processed within 72 hours if medical urgency is documented.

What if Pemazyre isn't on my UnitedHealthcare formulary? Non-formulary drugs can still be covered through the medical exception process. Your doctor must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Can I get an expedited appeal in Georgia? Yes, if delaying treatment could seriously harm your health. Request expedited review when filing your appeal, and Georgia DOI offers 72-hour external review for urgent cases.

Do I need a lawyer for appeals in Georgia? No, Georgia's external review process is designed for consumers to navigate without legal representation. The Georgia DOI Consumer Services hotline (1-800-656-2298) provides free assistance.

What happens if my doctor won't help with appeals? You have the right to file appeals yourself. Contact UnitedHealthcare member services and Georgia DOI for guidance. Consider seeking a second opinion or consulting with an oncology specialist familiar with FGFR inhibitors.

Does step therapy apply if I've failed treatments in another state? Yes, treatment history from other states counts. Ensure your new doctor has complete records of prior therapies and their outcomes.

How do I prove FGFR alteration for coverage? You need a molecular pathology report from a certified lab showing FGFR2 fusion or rearrangement. Next-generation sequencing or other validated testing methods are typically required.

What if UnitedHealthcare requires a different FGFR inhibitor first? If your plan has step therapy requiring futibatinib (Lytgobi) first, your doctor can request an exception based on clinical factors like drug availability, contraindications, or treatment urgency.

Medical Disclaimer: This information is for educational purposes only and doesn't constitute medical advice. Treatment decisions should be made in consultation with qualified healthcare providers familiar with your specific medical situation.

Appeals Assistance: For personalized help with UnitedHealthcare appeals in Georgia, contact Counterforce Health, which specializes in turning insurance denials into successful appeals through evidence-based documentation and payer-specific strategies.

Sources & Further Reading

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