By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (selpercatinib) Covered by UnitedHealthcare in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Retevmo Covered by UnitedHealthcare in New Jersey

Retevmo (selpercatinib) requires prior authorization from UnitedHealthcare OptumRx. Key requirements include FDA-approved RET fusion testing, specific cancer diagnosis documentation, and possible step therapy compliance. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) provides external review after internal appeals.

Three steps to start today:

  1. Gather RET fusion test results from an FDA-approved diagnostic
  2. Submit prior authorization through UnitedHealthcare Provider Portal
  3. If denied, file internal appeal within 180 days

First action: Contact your oncologist to confirm RET testing meets UnitedHealthcare's requirements.

Table of Contents

  1. Coverage Requirements Overview
  2. Prior Authorization Process
  3. Common Denial Reasons & Solutions
  4. Appeals Process in New Jersey
  5. Required Documentation Checklist
  6. Cost and Financial Assistance
  7. When to Escalate
  8. Frequently Asked Questions

Coverage Requirements Overview

UnitedHealthcare covers Retevmo (selpercatinib) for patients with RET fusion-positive cancers, but prior authorization is mandatory. The drug costs approximately $23,000-$26,000 per month, making insurance coverage essential for most patients.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all prescriptions UHC Provider Portal UHC PA Requirements
RET Testing FDA-approved companion diagnostic Pathology report UHC Retevmo Policy
Step Therapy May require prior treatments Medical records OptumRx Formulary
Diagnosis Codes C34.x (NSCLC) or C73 (thyroid) Oncology notes Clinical documentation
Reauthorization Every 12 months Provider submission UHC PA Policy

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm RET Testing (Patient/Oncologist)
    • Ensure testing used FDA-approved companion diagnostic (FoundationOne CDx, Oncomine Dx Target Test)
    • Document specific RET fusion or mutation in pathology report
    • Timeline: Results typically available within 7-14 days
  2. Gather Clinical Documentation (Clinic Staff)
    • Collect diagnosis codes (C34.x for NSCLC, C73 for thyroid cancer)
    • Document prior therapies attempted and outcomes
    • Include staging and performance status
    • Timeline: 1-2 business days
  3. Submit Prior Authorization (Prescriber)
    • Use UnitedHealthcare Provider Portal
    • Alternative: CoverMyMeds or fax submission
    • Include all supporting documentation
    • Timeline: Submit within 24-48 hours of prescription
  4. Track Authorization Status (Patient/Clinic)
    • Check portal for updates every 2-3 business days
    • UnitedHealthcare typically responds within 72 hours for urgent cases
    • Standard reviews: 5-10 business days
  5. Address Additional Information Requests (Prescriber)
    • Respond within 14 days to avoid denial
    • Provide peer-to-peer review if requested
    • Timeline: Same day for urgent requests
  6. Receive Authorization (Pharmacy/Patient)
    • Authorization typically valid for 12 months
    • Schedule reauthorization 30 days before expiration
    • Begin treatment as prescribed

Clinician Corner: Medical Necessity Letter

When submitting prior authorization, include a comprehensive medical necessity letter addressing:

Essential Elements:

  • Problem Statement: "Patient has [specific cancer type] with confirmed RET fusion/mutation"
  • Testing Documentation: "RET alteration confirmed by [FDA-approved test name] on [date]"
  • Prior Treatments: List previous therapies, durations, and reasons for discontinuation
  • Clinical Rationale: Reference FDA labeling and NCCN guidelines
  • Monitoring Plan: Address QT prolongation risk and drug interactions
Note: Include specific test methodology and laboratory information, as UnitedHealthcare may deny claims lacking FDA-approved companion diagnostic documentation.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documents
Missing RET testing Submit FDA-approved test results Pathology report with specific RET alteration
Step therapy not met Request exception or document failures Prior therapy records, contraindication notes
Insufficient diagnosis documentation Provide complete staging information Oncology notes, imaging reports
QT prolongation concerns Address cardiac monitoring plan EKG results, cardiology clearance
Not medically necessary Submit peer-to-peer review request Clinical literature, guideline references

Most Effective Appeal Strategies

For Missing Documentation:

  • Resubmit with complete pathology reports
  • Highlight FDA-approved testing methodology
  • Include laboratory accreditation information

For Step Therapy Issues:

  • Document specific contraindications to required therapies
  • Provide evidence of prior treatment failures
  • Reference patient-specific factors (allergies, comorbidities)

Appeals Process in New Jersey

New Jersey offers robust appeal rights through a two-tier internal process followed by external review through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals Timeline

Stage 1 Appeal:

  • Deadline: 180 days from denial date
  • Review Time: 72 hours (urgent) or 10 days (standard)
  • Reviewer: UnitedHealthcare medical director
  • Submission: UHC Provider Portal or mail

Stage 2 Appeal (Group Plans):

  • Deadline: 180 days from Stage 1 denial
  • Review Time: 72 hours (urgent) or 20 business days (standard)
  • Reviewer: Independent physician panel
  • Submission: Same methods as Stage 1

IHCAP External Review

After exhausting internal appeals, New Jersey residents can access external review through the Independent Health Care Appeals Program.

Key Features:

  • Eligibility: Fully insured plans (not self-insured ERISA plans)
  • Timeline: 4 months (180 days) from final internal denial
  • Cost: Free to patients (insurers pay all fees)
  • Decision: Binding on insurance company
  • Success Rate: Approximately 50% of external appeals favor consumers

How to File:

  1. Complete internal appeals first
  2. Submit request to Maximus Federal Services (contracted IURO)
  3. Include all medical records and denial letters
  4. Request expedited review if urgent medical need
Tip: New Jersey's external review process is particularly strong for cancer medications, as the state requires specialty-matched physician reviewers.

Required Documentation Checklist

Before Starting Your Prior Authorization

Insurance Information:

  • UnitedHealthcare member ID and group number
  • Policy effective dates and coverage verification
  • OptumRx pharmacy benefit confirmation

Medical Documentation:

  • RET fusion/mutation test results (FDA-approved diagnostic)
  • Complete pathology report with tumor type and staging
  • Oncology consultation notes
  • Prior treatment history and outcomes
  • Current performance status assessment

Clinical Support:

  • ICD-10 diagnosis codes (C34.x or C73)
  • HCPCS J-code J9380 for billing
  • NDC numbers for specific Retevmo strengths
  • Dosing rationale (160 mg twice daily standard)

Safety Monitoring:

  • Baseline EKG (QT interval assessment)
  • Current medication list (QT-prolonging drug review)
  • Liver function tests
  • Drug interaction assessment

Cost and Financial Assistance

Manufacturer Support

Lilly Cares Foundation:

  • Income-based assistance for eligible patients
  • May cover up to 100% of medication cost
  • Application available at LillyCares.com

Retevmo Copay Program:

  • Commercial insurance patients may pay as little as $10/month
  • Income and insurance restrictions apply
  • Enrollment through prescriber or pharmacy

State and Federal Programs

New Jersey Pharmaceutical Assistance Programs:

  • PAAD (Pharmaceutical Assistance to the Aged and Disabled)
  • Senior Gold Prescription Discount Program
  • Contact: 1-800-792-9745

When to Escalate

Contact New Jersey regulators if you experience:

  • Unreasonable delays in prior authorization review
  • Repeated denials without clear medical justification
  • Failure to follow state appeal procedures

New Jersey Department of Banking and Insurance:

  • Consumer Hotline: 1-800-446-7467
  • IHCAP Specific: 1-888-393-1062
  • Online complaints: NJ DOBI Website
From Our Advocates: "We've seen several cases where UnitedHealthcare initially denied Retevmo due to 'investigational' status, despite FDA approval. In these situations, submitting the FDA approval letter alongside the appeal typically resolves the issue within one review cycle. The key is being persistent with documentation while following New Jersey's structured appeal process."

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in New Jersey? Standard reviews typically take 5-10 business days. Urgent cases (life-threatening conditions) must be reviewed within 72 hours per UHC policy.

What if Retevmo is not on my formulary? UnitedHealthcare typically covers Retevmo on specialty tiers requiring prior authorization. If listed as non-formulary, request a formulary exception with clinical justification.

Can I request an expedited appeal in New Jersey? Yes, both internal appeals and IHCAP external review offer expedited processes for urgent medical situations. Document the urgency clearly in your appeal.

Does step therapy apply if I received prior treatment outside New Jersey? Treatment history from any location should count toward step therapy requirements. Provide complete documentation of all prior therapies regardless of where received.

What happens if my appeal is denied? After exhausting UnitedHealthcare's internal appeals, you have 180 days to file with New Jersey's IHCAP external review program, which provides binding decisions.

How do I know if my plan is subject to New Jersey appeal rights? Fully insured plans purchased in New Jersey are subject to state appeal laws. Self-insured employer plans follow federal ERISA procedures instead.

Can my doctor file appeals on my behalf? Yes, New Jersey allows providers to file external appeals with patient consent. Many oncology practices have dedicated staff for this process.

What if I need Retevmo immediately while appeals are pending? Request expedited review at every level. Consider manufacturer patient assistance programs or hospital charity care while appeals are processed.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify specific denial reasons and draft point-by-point rebuttals aligned with each payer's requirements. For complex cases like Retevmo approvals, we help ensure all FDA testing requirements and clinical documentation meet UnitedHealthcare's specific criteria.

The system tracks New Jersey's appeal deadlines and procedural requirements while providing templates that meet both UnitedHealthcare's internal review standards and IHCAP external review expectations. Clinicians get time-saving documentation templates, while patients receive plain-language guidance on next steps and required forms.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider for medical decisions. For personalized assistance with appeals in New Jersey, contact the Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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