How to Get Retevmo (Selpercatinib) Covered by UnitedHealthcare in Virginia: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Retevmo Covered by UnitedHealthcare in Virginia
UnitedHealthcare requires prior authorization for Retevmo (selpercatinib) with RET alteration testing via FDA-approved diagnostics like FoundationOne CDx. The fastest path: (1) Gather RET fusion/mutation test results and complete pathology reports, (2) Submit PA through UnitedHealthcare Provider Portal with oncology consultation notes, (3) If denied, file internal appeal within 180 days, then Virginia external review via Form 216-A within 120 days. Start today: Contact your oncologist to confirm RET testing is complete and request prior therapy documentation for the PA submission.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Playbook for UnitedHealthcare in Virginia
- Costs & Patient Assistance Programs
- When to Escalate: Virginia State Resources
- Frequently Asked Questions
- Sources & Further Reading
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Required for all Retevmo prescriptions | UnitedHealthcare Provider Portal | UHC PA Requirements |
| RET Alteration Testing | FDA-approved diagnostic (FoundationOne CDx) confirming RET fusion/mutation | Pathology report with test results | FDA Approval Notice |
| Disease Status | Advanced, metastatic, or recurrent NSCLC/thyroid cancer | Oncology consultation notes | UHC Coverage Criteria |
| Authorization Duration | 12 months for initial and reauthorizations | UnitedHealthcare policy | UHC PA Requirements |
| Appeals Deadline | 180 days from denial for internal; 120 days for Virginia external review | Denial letter and Virginia SCC | Virginia External Review |
Step-by-Step: Fastest Path to Approval
1. Confirm RET Testing is Complete
Who: Patient and oncologist
Document needed: FoundationOne CDx or equivalent FDA-approved RET alteration test
Timeline: Test results typically available within 7-14 days
Source: FDA-Approved Companion Diagnostics
2. Gather Required Documentation
Who: Clinic staff
Documents needed:
- Complete pathology report with tumor staging
- RET fusion/mutation test results
- Prior treatment history and outcomes
- Current performance status assessment
- Diagnosis codes (C34.x for NSCLC, C73 for thyroid cancer)
3. Submit Prior Authorization
Who: Prescribing physician
How to submit: UnitedHealthcare Provider Portal, CoverMyMeds, or fax
Expected timeline: 5-10 business days (72 hours for urgent cases)
Source: UHC Provider Portal
4. Monitor PA Status
Who: Patient or clinic
Where: UnitedHealthcare member portal or provider TrackIt system
Action if approved: Prescription can be filled
Action if denied: Proceed to step 5
5. Request Peer-to-Peer Review (Optional)
Who: Prescribing physician
Timeline: Within 24 hours of denial notification
Purpose: Discuss case directly with UnitedHealthcare medical director
Source: UHC Appeals Process
6. File Internal Appeal
Who: Patient, physician, or authorized representative
Timeline: Within 180 days of denial
How: UnitedHealthcare Provider Portal or written submission
Expected resolution: 30 days (standard), 72 hours (expedited)
7. Virginia External Review (If Internal Appeal Fails)
Who: Patient or authorized representative
Form: Form 216-A for standard review
Timeline: Within 120 days of final internal denial
Submit to: Virginia SCC Bureau of Insurance
Source: Virginia External Review Process
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| Missing RET alteration documentation | Submit FDA-approved test results | FoundationOne CDx report showing RET fusion/mutation |
| Insufficient disease staging | Provide complete pathology report | Pathology confirming advanced/metastatic disease |
| Step therapy not met | Document contraindications or prior failures | Medical records showing intolerance or ineffectiveness of alternatives |
| "Not medically necessary" | Submit clinical evidence and guidelines | Oncology consultation notes, NCCN guidelines, FDA labeling |
| Wrong tumor type | Clarify diagnosis with ICD-10 codes | Updated pathology report with correct cancer classification |
Clinician Corner: Medical Necessity Letter Checklist
When drafting your medical necessity letter, include:Problem statement: Patient's specific cancer diagnosis and RET alteration statusPrior treatments: Document all previous therapies, outcomes, and reasons for discontinuationClinical rationale: Explain why Retevmo is the appropriate next-line therapyGuideline support: Reference NCCN guidelines and FDA labeling for RET-positive cancersMonitoring plan: Detail your approach to managing potential side effects and drug interactions
Appeals Playbook for UnitedHealthcare in Virginia
Internal Appeals Process
Level 1 - Standard Appeal
- Deadline: 180 days from denial
- Timeline: 30 days for resolution
- How to file: UnitedHealthcare Provider Portal or written submission
- Required: Denial letter, medical records, physician statement
Level 1 - Expedited Appeal
- When to use: Life-threatening conditions or serious health consequences
- Timeline: 72 hours for resolution
- Required: Physician certification of urgency
Virginia External Review
Eligibility Requirements:
- Completed UnitedHealthcare's internal appeals process
- Non-grandfathered health plan issued after July 1, 2011
- Denial based on medical necessity or experimental treatment determination
Standard External Review
- Form: Form 216-A (External Review Request)
- Deadline: 120 days from final internal denial
- Timeline: 45 days for IRO decision
- Cost: Free to patient
Expedited External Review
- Form: Form 216-A plus Form 216-C (Physician Certification)
- When to use: Delay would seriously jeopardize life, health, or function
- Timeline: 72 hours for IRO decision
How to Submit Virginia External Review:
- Fax: 804-371-9915
- Email: [email protected]
- Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
Source: Virginia External Review Regulations
Costs & Patient Assistance Programs
Retevmo Pricing: Cash prices range from $23,000-$26,000 per 30-day supply depending on strength.
Manufacturer Support:
- Lilly Cares Foundation: Income-based patient assistance program
- Eligibility: Varies by income and insurance status
- Contact: Visit LillyCares.com or call 1-833-808-1234
Additional Resources:
- CancerCare: Free oncology social work services and financial assistance
- Patient Advocate Foundation: Copay relief and case management
- NeedyMeds: Database of patient assistance programs
From Our Advocates: We've seen patients successfully obtain Retevmo coverage after initial denials by working closely with their oncology team to document prior treatment failures and emphasizing the urgency of targeted therapy for RET-positive cancers. The key is thorough documentation and persistence through the appeals process—many denials are overturned when complete clinical information is provided.
When to Escalate: Virginia State Resources
Virginia Managed Care Ombudsman
Contact: 1-877-310-6560 (toll-free) or 804-371-9032 (Richmond)
Email: [email protected]
Services: Free assistance with managed care plan issues and informal dispute resolution
Virginia State Corporation Commission Bureau of Insurance
Consumer Services: 1-800-552-7945
Mail: P.O. Box 1157, Richmond, VA 23218
Services: Insurance complaint investigation and regulatory enforcement
Legal Assistance
Virginia Poverty Law Center Health Assistance Program
Hotline: (844) 430-1727 (Mon-Fri, 9AM-4:30PM)
Services: Free legal aid for low-income residents with health insurance appeals
At Counterforce Health, we specialize in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for medications like Retevmo.
Frequently Asked Questions
How long does UnitedHealthcare prior authorization take for Retevmo in Virginia? Standard reviews take 5-10 business days. Urgent cases involving life-threatening conditions are reviewed within 72 hours per UnitedHealthcare policy.
What if Retevmo is non-formulary on my UnitedHealthcare plan? You can request a formulary exception through the prior authorization process. Provide medical necessity documentation and evidence that formulary alternatives are inappropriate or have failed.
Can I request an expedited appeal if my oncologist says treatment is urgent? Yes. Your physician must certify that waiting for standard review would seriously jeopardize your life, health, or ability to regain function. Expedited appeals are resolved within 72 hours.
Does step therapy apply if I've already failed other treatments outside Virginia? Treatment history from other states is typically accepted. Provide complete medical records documenting prior therapies, outcomes, and reasons for discontinuation.
What happens if UnitedHealthcare denies my internal appeal? You can file for Virginia external review using Form 216-A within 120 days of the final denial. An independent review organization will make a binding decision on your case.
How much does the Virginia external review process cost? Virginia external review is free to patients. The state covers all costs associated with the independent review process.
Can someone file an appeal on my behalf? Yes. Use Form 216-B (Authorized Representative) to designate someone to act on your behalf during the appeals process.
What if I have a self-funded employer plan? Many Virginia-based self-funded plans opt into the state's external review process. If not, you may have federal external review rights through HHS. Contact the Virginia Bureau of Insurance for guidance.
Sources & Further Reading
- UnitedHealthcare Retevmo Prior Authorization Requirements (PDF)
- Virginia External Review Regulations
- FDA Approval: FoundationOne CDx for Selpercatinib
- UnitedHealthcare Provider Portal Appeals Process
- Virginia SCC Bureau of Insurance Consumer Services
- Retevmo FDA Prescribing Information
For additional support with complex prior authorization and appeals processes, Counterforce Health provides specialized assistance in creating evidence-backed appeals that align with payer policies and clinical guidelines.
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and contact Virginia state resources or qualified legal counsel for specific appeals guidance. Coverage policies and requirements may change; verify current information with UnitedHealthcare and Virginia regulators.
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