By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (selpercatinib) Covered by UnitedHealthcare in North Carolina: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Retevmo Covered by UnitedHealthcare in North Carolina

Fastest path to approval: Submit prior authorization with FDA-approved RET fusion test results, diagnosis documentation, and prior therapy history through UnitedHealthcare's provider portal. If denied, North Carolina law provides strong step therapy exception rights (72-hour response required) and external review through Smart NC within 120 days. Start today: Gather your RET fusion test results from an FDA-approved companion diagnostic and contact your oncologist to initiate the prior authorization process.

Table of Contents

  1. Why North Carolina State Rules Matter
  2. UnitedHealthcare Prior Authorization Requirements
  3. North Carolina Step Therapy Protections
  4. Appeals Process: Internal to External Review
  5. Timeline Standards and Urgent Reviews
  6. Common Denial Reasons and How to Fix Them
  7. Smart NC External Review Process
  8. Scripts and Practical Tools
  9. Cost Support Options
  10. FAQ

Why North Carolina State Rules Matter

North Carolina's insurance laws provide significant protections for patients seeking specialty cancer medications like Retevmo (selpercatinib). These state rules work alongside UnitedHealthcare's policies to create additional pathways for coverage when initial requests are denied.

Key North Carolina protections include:

  • Step therapy exceptions with mandatory 72-hour response times for standard requests (24 hours for urgent)
  • External review rights through Smart NC for medical necessity denials
  • Consumer assistance through the Department of Insurance helpline at 855-408-1212
Note: These protections apply to fully insured UnitedHealthcare plans regulated by North Carolina law. Self-funded employer plans may have different processes, though many opt into state protections.

UnitedHealthcare Prior Authorization Requirements

Retevmo requires prior authorization through UnitedHealthcare's OptumRx pharmacy benefit management system. Here's what you need to know:

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Retevmo prescriptions UHC Provider Portal
RET Fusion Test FDA-approved companion diagnostic required FDA labeling, pathology report
Step Therapy May apply depending on cancer type and history Plan formulary documents
Quantity Limits Typically 30-day supply OptumRx formulary
Reauthorization Required every 12 months UHC policy documents

Required Documentation

For your oncologist to submit:

  • Confirmed RET fusion using an FDA-approved test (Oncomine Dx Target Test, FoundationOne CDx, or Illumina TSO Comprehensive)
  • Diagnosis of locally advanced or metastatic NSCLC or thyroid cancer
  • Documentation of prior therapies tried and failed (if step therapy applies)
  • Clinical rationale for Retevmo over alternatives
  • Patient's current performance status and treatment goals

North Carolina Step Therapy Protections

North Carolina's S.B. 361 (effective October 2020) requires insurers to provide clear medical exception processes for step therapy protocols. This is particularly important for Retevmo, as UnitedHealthcare often requires patients to try other therapies first.

Exception Criteria

You can request a step therapy exception if:

  • The required step therapy drug would likely cause an adverse reaction
  • The step therapy drug would be ineffective based on your medical history
  • You've previously tried and failed the required drug
  • You're already stable on your current treatment
  • The step therapy would prevent you from performing daily activities

Response Timeframes

  • Standard requests: 72 hours maximum
  • Urgent requests: 24 hours maximum
Tip: Document any prior treatment failures thoroughly, including dates, dosages, duration of treatment, and specific reasons for discontinuation (lack of efficacy, intolerance, contraindications).

Appeals Process: Internal to External Review

If your initial prior authorization is denied, North Carolina provides a structured appeals pathway:

Step-by-Step Appeals Process

  1. Peer-to-Peer Review (Optional, within 24 hours of denial)
    • Your oncologist can request a direct discussion with a UnitedHealthcare medical director
    • Submit request through provider portal or by calling the number on the denial letter
  2. Internal Appeal Level 1 (Within 180 days of denial)
    • Submit through UnitedHealthcare provider portal or member services
    • Include all supporting documentation and medical records
    • Decision typically within 15-30 days (72 hours for urgent cases)
  3. Internal Appeal Level 2 (If Level 1 denied)
    • Second-level review by different UnitedHealthcare personnel
    • Same timeline and documentation requirements
  4. External Review through Smart NC (Within 120 days of final internal denial)
    • Independent review by clinical experts not employed by UnitedHealthcare
    • Decision binding on the insurer

Timeline Standards and Urgent Reviews

Standard vs. Urgent Criteria

Standard Review:

  • Non-life-threatening situations
  • Stable patients who can wait for standard processing
  • Timeline: Up to 30 days for initial PA, 72 hours for step therapy exceptions

Urgent/Expedited Review:

  • Serious risk to health, life, or ability to regain function if treatment delayed
  • Progressive cancer requiring immediate intervention
  • Timeline: 24-72 hours for most decisions
Important: For rapidly progressing cancers, always request expedited review and provide clinical documentation supporting the urgency.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn
Missing RET fusion test Submit FDA-approved companion diagnostic results
Wrong tumor type Provide pathology confirming NSCLC or thyroid cancer
Step therapy not completed Request medical exception with prior failure documentation
"Not medically necessary" Submit clinical guidelines supporting Retevmo use
Quantity limit exceeded Provide dosing rationale based on patient weight/BSA

Medical Necessity Documentation

When challenging a "not medically necessary" denial, include:

  • FDA labeling supporting the indication
  • Peer-reviewed studies demonstrating efficacy in RET-positive tumors
  • Professional society guidelines (NCCN, ASCO)
  • Patient-specific factors making Retevmo the optimal choice

Smart NC External Review Process

North Carolina's Smart NC program provides free external review services for UnitedHealthcare denials related to medical necessity.

Eligibility Requirements

  • You must have a state-regulated UnitedHealthcare plan (not self-funded)
  • All internal appeals must be completed first
  • Request must be submitted within 120 days of final denial
  • Denial must relate to medical necessity, experimental treatment determination, or similar coverage issues

How to Submit

  1. Complete the External Review Request Form available at NC Department of Insurance website
  2. Attach required documents:
    • Final denial letter from UnitedHealthcare
    • Medical records supporting the need for Retevmo
    • Any additional clinical evidence
  3. Submit via:
    • Online portal through NC Department of Insurance
    • Mail to Smart NC (address on the form)
    • Phone: 855-408-1212 for assistance

Timeline for External Review

  • Standard review: Decision within 45 days
  • Expedited review: Decision within 3-4 business days for urgent cases

Scripts and Practical Tools

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about my prior authorization request for Retevmo (selpercatinib). My member ID is [ID number]. I have RET fusion-positive lung cancer, and my oncologist submitted a PA request on [date]. I'd like to check the status and understand any additional documentation needed. If this is denied, I'd also like information about requesting an expedited appeal given my cancer diagnosis."

Clinician Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for my patient's Retevmo prior authorization. The patient has confirmed RET fusion-positive NSCLC with [specific mutation details] detected by [FDA-approved test name]. Given the targeted nature of this therapy and the patient's [clinical circumstances], I believe Retevmo is the most appropriate first-line treatment. I'm available for a call at [times] to discuss the clinical rationale."

Cost Support Options

While working through the approval process, explore these cost assistance programs:

Manufacturer Support

  • Lilly Cares Foundation: Patient assistance program for eligible uninsured/underinsured patients
  • Retevmo Savings Program: Copay assistance for commercially insured patients
  • Contact: Lilly patient support website

Additional Resources

  • CancerCare Financial Assistance: Grants for treatment-related costs
  • Patient Advocate Foundation: Copay relief program for cancer patients
  • North Carolina Cancer Fund: State-specific assistance programs

When working through insurance challenges, organizations like Counterforce Health can help patients and providers navigate the complex prior authorization and appeals process by creating evidence-based appeals that address specific payer requirements and denial reasons.

FAQ

Q: How long does UnitedHealthcare prior authorization take in North Carolina? A: Standard prior authorization decisions are typically made within 15-30 days. Urgent requests must be processed within 72 hours. If step therapy exceptions are needed, North Carolina law requires responses within 72 hours (24 hours for urgent cases).

Q: What if Retevmo is non-formulary on my UnitedHealthcare plan? A: Non-formulary medications can still be covered through the medical exception process. Your oncologist will need to provide clinical justification for why formulary alternatives are inappropriate for your specific case.

Q: Can I request an expedited appeal for Retevmo? A: Yes, if waiting for a standard appeal timeline would seriously jeopardize your health or ability to regain function. Cancer patients often qualify for expedited reviews given the progressive nature of the disease.

Q: Does North Carolina step therapy law apply to all UnitedHealthcare plans? A: The step therapy protections apply to state-regulated plans. Self-funded employer plans may not be covered, though many voluntarily adopt similar protections. Check with your HR department or plan documents.

Q: What happens if Smart NC external review overturns UnitedHealthcare's denial? A: The decision is binding on UnitedHealthcare. They must provide coverage within 3 business days of receiving the external review decision.

Q: How much does Retevmo cost without insurance? A: Cash prices typically range from $23,000-$26,000 per 30-day supply, depending on the strength prescribed. This makes insurance coverage critical for most patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific situation. Insurance coverage policies change frequently—verify current requirements with UnitedHealthcare and consult the North Carolina Department of Insurance for the most up-to-date appeal procedures. For personalized assistance with complex prior authorization and appeals processes, Counterforce Health specializes in helping patients and clinicians navigate insurance denials with evidence-based appeals strategies.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.