By Counterforce Health Team in Pemazyre (pemigatinib) —

How to Get Pemazyre (pemigatinib) Covered by UnitedHealthcare in Pennsylvania: Complete Forms, Appeals, and Approval Guide

Answer Box: Getting Pemazyre Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Pemazyre (pemigatinib) effective January 1, 2025. To get coverage in Pennsylvania: (1) Confirm your FGFR2 fusion/rearrangement test results are documented, (2) Have your oncologist submit a PA request through the UHC Provider Portal with all required clinical documentation, and (3) If denied, use Pennsylvania's new external review process—which overturns about 50% of denials—within four months of your final denial letter. Submit requests online at pa.gov/reviewmyclaim.

Table of Contents

  1. Start Here: Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Process
  4. Specialty Pharmacy Enrollment
  5. Appeals Process: Internal and External
  6. Support Contacts and Resources
  7. Pennsylvania External Review Process
  8. Common Denial Reasons and Solutions
  9. Cost Assistance Options
  10. FAQ

Start Here: Verify Your Plan and Find the Right Forms

Before starting your Pemazyre coverage journey, confirm your UnitedHealthcare plan type and benefits. Log into myuhc.com or call the member services number on your ID card to verify:

  • Prescription drug coverage is included in your plan
  • Specialty drug tier and your coinsurance percentage
  • Whether you're enrolled in OptumRx for pharmacy benefits
  • Your plan's specific prior authorization requirements
Note: If you have a Medicare Advantage plan, different timelines may apply compared to commercial coverage.

Plan Types in Pennsylvania:

  • Commercial/Employer plans: Standard PA process through OptumRx
  • Medicare Advantage: May have additional CMS requirements
  • Medicaid (Community Plan): State-specific PA forms may apply
  • Marketplace/ACA plans: Follow commercial PA process

Prior Authorization Forms and Requirements

Coverage Requirements for Pemazyre

UnitedHealthcare requires prior authorization for Pemazyre with these specific criteria:

For Cholangiocarcinoma (all must be met):

  • Diagnosis of unresectable locally advanced or metastatic cholangiocarcinoma
  • FGFR2 fusion or other rearrangement detected by FDA-approved test
  • Patient has been previously treated

For Myeloid/Lymphoid Neoplasms:

  • Diagnosis with FGFR1 rearrangement
  • Relapsed or refractory disease

Authorization period: 12 months upon approval.

Required Documentation Checklist

Your oncologist must submit:

  • FGFR2/FGFR1 fusion test results (from FDA-approved assay)
  • Prior therapy records with specific dates and outcomes
  • Pathology report confirming diagnosis
  • Recent imaging reports showing disease status
  • Baseline ophthalmology exam results (monitoring required)
  • Current medication list with CYP3A4 interaction assessment
  • Treatment plan and goals

Submission Portals and Upload Process

UnitedHealthcare Provider Portal

Healthcare providers should submit PA requests through the UHC Provider Portal.

Portal Access Requirements:

  • One Healthcare ID with multi-factor authentication
  • Passkey, authenticator app + phone, or password + phone
  • Recovery code (20-digit backup access code)

Submission Timeline:

  • Standard requests: Decided within 72 hours
  • Expedited requests: Decided within 24 hours

For Members: Checking Status

Log into your member portal at myuhc.com to:

  • Track PA request status
  • View denial reasons if applicable
  • Download denial letters for appeals
  • Check specialty pharmacy transfer status

Specialty Pharmacy Enrollment

Optum Specialty Pharmacy Network

Optum Specialty Pharmacy is UnitedHealthcare's primary network for Pemazyre dispensing. Your oncologist should send prescriptions directly to Optum rather than retail pharmacies.

Enrollment Steps:

  1. Confirm network participation by calling member services
  2. Verify specialty drug benefits and copay responsibility
  3. Coordinate prescription transfer from current pharmacy
  4. Set up delivery preferences (typically overnight shipping included)
  5. Plan refill coordination (calls typically 5-7 days before refill needed)

Cost Considerations:

  • Pemazyre is on the specialty tier (typically 20-33% coinsurance)
  • IncyteCARES copay assistance may reduce costs to $0/month for eligible commercial patients

Appeals Process: Internal and External

UnitedHealthcare Internal Appeals

If your initial PA is denied, you have 180 days from the denial date to file an internal appeal.

Internal Appeal Process:

  1. Gather additional evidence (peer-reviewed studies, treatment guidelines)
  2. Submit through member portal or mail to address on denial letter
  3. Request peer-to-peer review if appropriate
  4. Standard timeline: Up to 30 days for decision
  5. Expedited timeline: 72 hours for urgent cases

Medical Necessity Documentation

For appeals, strengthen your case with:

  • Clinical guidelines supporting Pemazyre use
  • Peer-reviewed studies on FGFR-targeted therapy
  • Documentation of contraindications to step therapy alternatives
  • Treatment failure history with prior therapies
From our advocates: We've seen cases where initial denials were overturned after submitting molecular testing reports with clear FGFR2 fusion documentation and a detailed letter explaining why standard chemotherapy alternatives weren't appropriate. The key is connecting your specific biomarker results to the FDA-approved indication.

Pennsylvania External Review Process

When Internal Appeals Fail

Pennsylvania launched its Independent External Review Program in January 2024, with impressive results: 50% of appeals are overturned, forcing insurers to cover initially denied treatments.

Eligibility Requirements:

  • Must complete UnitedHealthcare's internal appeal process
  • Receive a Final Adverse Benefit Determination Letter
  • Submit external review request within 4 months of final denial

Submission Methods (fastest processing):

  • Online: pa.gov/reviewmyclaim
  • Email or fax: Timelines begin immediately upon receipt
  • Mail: Timeline begins when PID receives your request

External Review Timeline

Standard Reviews:

  • Within 5 business days: Eligibility determination
  • Within 1 business day: Independent review organization assigned
  • Within 15 business days: You can submit additional medical information
  • Within 45 days: Final decision issued

Expedited Reviews (life-threatening situations):

  • Within 24 hours: Request processed and reviewer assigned
  • Within 72 hours: Decision issued
  • Within 24 hours of decision: Insurer must implement coverage

Support Contacts and Resources

UnitedHealthcare Contact Numbers

  • Member Services: Number on your ID card
  • Provider Services: 855-819-5909
  • OptumRx (Pharmacy): 800-711-4555
  • 24/7 Portal Chat: Available within provider portal

Pennsylvania Consumer Assistance

  • PA Insurance Department Consumer Services: 1-877-881-6388
  • Pennsylvania Health Law Project: Free appeals assistance for low-income individuals
  • Pennie (PA Marketplace): Consumer hotline for marketplace plan issues

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
No FGFR alteration documented Submit FDA-approved biomarker test FoundationOne, Guardant360, or equivalent report
Off-label line of therapy Cite FDA indication and guidelines Prescribing information, NCCN guidelines
Missing ophthalmology monitoring Schedule baseline exam Ophthalmology consultation note
Drug interaction concerns Review and adjust medications Updated medication list, interaction assessment
Quantity limit exceeded Justify dosing requirements Weight-based dosing calculation, FDA label

Cost Assistance Options

Manufacturer Support Programs

IncyteCARES Program:

  • Commercial insurance patients: Potential $0 copay
  • Uninsured patients: Case-by-case assistance
  • Medicare patients: Limited assistance due to federal restrictions

Additional Resources

  • Patient Advocate Foundation: Financial assistance for qualifying patients
  • CancerCare: Free case management and limited financial assistance
  • Leukemia & Lymphoma Society: Copay assistance for blood cancers

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals aligned to the plan's specific requirements, pulling the right citations and clinical evidence to strengthen your case.

FAQ

How long does UnitedHealthcare PA take in Pennsylvania? Standard requests are decided within 72 hours; expedited requests within 24 hours.

What if Pemazyre is non-formulary on my plan? You can appeal for a formulary exception with medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if your condition is life-threatening or could seriously jeopardize your health without immediate treatment.

Does step therapy apply if I've failed therapies outside Pennsylvania? Yes, document all prior therapy failures regardless of where treatment occurred.

What's the success rate for external reviews in Pennsylvania? Pennsylvania's external review program overturned about 50% of denials in its first year (2024).

Can I get help with the appeals process? Yes, contact the Pennsylvania Health Law Project for free assistance, especially if you qualify for low-income support.

What if my oncologist isn't familiar with UnitedHealthcare's requirements? Share this guide and the official PA notification form. Counterforce Health can also help clinicians navigate complex PA requirements and appeal processes.

How do I know if my FGFR test is FDA-approved? Common FDA-approved tests include FoundationOne CDx, Guardant360, and MSK-IMPACT. Check with your oncologist or testing laboratory.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional support with complex appeals, consider consulting with healthcare coverage specialists or patient advocacy organizations.

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