By Counterforce Health Team in Rezlidhia (olutasidenib) —

How to Get Rezlidhia (olutasidenib) Covered by UnitedHealthcare in Ohio: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Rezlidhia Covered in Ohio

Rezlidhia (olutasidenib) requires prior authorization through UnitedHealthcare's OptumRx. Submit your PA request online via the UnitedHealthcare Provider Portal with IDH1 mutation confirmation, AML diagnosis, and treatment history. If denied, you have 180 days for internal appeals, then external review through Ohio's Department of Insurance within 180 days of final denial. Start today: gather your IDH1 mutation test results and contact Rigel OneCare at rezlidhia.com/support for bridge therapy during approval.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required through OptumRx UHC Provider Portal OptumRx PA Guidelines
IDH1 Mutation Lab confirmation of R132H, R132C, or other susceptible mutations Molecular testing report FDA Label
AML Diagnosis Relapsed/refractory acute myeloid leukemia ICD-10 code C92.0x FDA Indication
Formulary Tier Specialty tier with $2,000 annual cap (2025) Plan documents UHC 2025 Changes
Step Therapy May require prior treatment documentation PA submission UHC Commercial PA Requirements

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

Timeline: Start immediately upon prescription

  • IDH1 mutation test results (FDA-approved assay)
  • Pathology report confirming AML diagnosis
  • Treatment history with dates, doses, and outcomes
  • Current lab values (CBC, comprehensive metabolic panel, LFTs)

2. Submit Prior Authorization (Clinic Staff)

Timeline: Within 24-48 hours of prescription

  • Log into UnitedHealthcare Provider Portal
  • Use Prior Authorization and Notification tool
  • Alternative: Call OptumRx at 1-800-711-4555 for drug-specific guidelines
  • Expected response: 15 business days (72 hours for expedited)

3. Request Bridge Therapy (Patient/Clinic)

Timeline: Same day as PA submission

  • Contact Rigel OneCare for temporary supply
  • Provide prescription and insurance denial letter
  • Bridge duration: Typically covers 30-60 days during approval process

4. Monitor PA Status (Patient)

Timeline: Check every 3-5 business days

  • Use UnitedHealthcare member portal or call member services
  • Document all interactions with reference numbers
  • Request expedited review if treatment delay poses clinical risk

5. Appeal if Denied (Patient/Clinic)

Timeline: Within 180 days of denial

  • Level 1 internal appeal: 30 days for determination
  • Level 2 internal appeal: 30 days for determination
  • External review through Ohio Department of Insurance: 180 days from final denial

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
IDH1 mutation not documented Submit molecular testing report FDA-approved IDH1 assay results showing R132H, R132C, or other mutations
Off-label use Provide NCCN guidelines reference NCCN AML Guidelines supporting use
Lack of monitoring plan Detail safety monitoring protocol Weekly labs months 1-2, then per FDA dosing guide
Non-oncology prescriber Transfer to hematology/oncology Board-certified specialist prescription required
Step therapy not met Document prior treatment failures Dates, doses, duration, and reason for discontinuation
From our advocates: We've seen cases where the initial denial cited "experimental use," but the appeal succeeded by highlighting Rezlidhia's FDA approval and NCCN inclusion. The key was submitting the complete molecular pathology report showing the specific IDH1 mutation—not just a summary statement.

Appeals Process for Ohio Residents

Internal Appeals with UnitedHealthcare

Level 1 Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for determination (72 hours expedited)
  • How to file: Member portal, phone, or mail
  • Success rate: Approximately 82% for oncology drugs with proper documentation

Level 2 Appeal

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for determination
  • Process: Independent medical review within UnitedHealthcare

External Review (Ohio Department of Insurance)

Eligibility: Medical necessity denials after exhausting internal appeals

  • Deadline: 180 days from final UnitedHealthcare denial
  • Cost: Free to patients
  • Timeline: 30 days standard, 72 hours expedited
  • Contact: Ohio DOI Consumer Services at 1-800-686-1526

Key Advantage: Even if UnitedHealthcare claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

The Independent Review Organization's decision is binding on UnitedHealthcare if approved.

Bridge Therapy & Patient Assistance

Manufacturer Support (Rigel OneCare)

  • Eligibility: Uninsured or underinsured patients unable to afford treatment
  • Coverage: Free Rezlidhia during PA process and for qualifying patients
  • Contact: rezlidhia.com/support
  • Timeline: 24-48 hours for approval

Financial Assistance Programs

Program Coverage Eligibility Contact
PAN Foundation AML Fund Up to $4,400/year copay assistance Income-based panfoundation.org
Leukemia & Lymphoma Society Treatment costs and copays Financial need lls.org
CancerCare Co-Payment Assistance Copay support Insurance coverage required cancercare.org

At Counterforce Health, we help patients navigate these exact scenarios—turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each payer's own rules.

Monitoring Requirements for Approval

Laboratory Monitoring Schedule

UnitedHealthcare typically requires documentation of your monitoring plan as part of the prior authorization:

Timeframe Lab Frequency Required Tests
Month 1-2 Weekly CBC, CMP, LFTs (ALT, AST, alkaline phosphatase, bilirubin)
Month 3 Every other week CBC, CMP, LFTs
Month 4 Monthly CBC, CMP, LFTs
Month 5+ Every other month CBC, CMP, LFTs

Key Safety Monitoring

  • Differentiation syndrome (16% incidence): Monitor for fever, dyspnea, weight gain
  • Hepatotoxicity: Baseline LFTs required; median onset 1.2 months
  • Dosing: 150 mg twice daily on empty stomach (≥1 hour before or 2 hours after meals)

Source: Rezlidhia Prescribing Information

Clinician Corner: Medical Necessity Letter

Your oncologist's medical necessity letter should include:

✓ Patient demographics and AML diagnosis with ICD-10 code
✓ IDH1 mutation details from FDA-approved testing
✓ Prior treatment history with specific dates, doses, and outcomes
✓ Clinical rationale referencing NCCN AML Guidelines
✓ Monitoring plan per FDA label requirements
✓ Treatment goals and expected duration

When to Escalate Your Case

Contact Ohio Department of Insurance if:

  • UnitedHealthcare delays response beyond stated timelines
  • Internal appeals are improperly denied
  • You need help understanding your rights

Ohio DOI Consumer Services: 1-800-686-1526
External Review: insurance.ohio.gov

Additional Resources

  • UHCAN Ohio (Universal Health Care Action Network): Consumer advocacy and legal referrals
  • Ohio Senior Health Insurance Information Program (OSHIIP): Medicare-related appeals

FAQ: UnitedHealthcare Rezlidhia Coverage

Q: How long does UnitedHealthcare prior authorization take for Rezlidhia?
A: Standard review takes 15 business days. Expedited review (for urgent cases) takes 72 hours. You can request expedited review if treatment delays pose clinical risk.

Q: What if Rezlidhia is non-formulary on my plan?
A: Rezlidhia is typically covered under specialty tiers with the $2,000 annual cap for 2025. Non-formulary drugs may require exception requests with clinical justification.

Q: Can I request an expedited appeal in Ohio?
A: Yes. Both internal appeals and external reviews offer expedited timelines (72 hours) when delays would seriously endanger your health.

Q: Does step therapy apply if I've tried treatments outside Ohio?
A: Prior treatments from any location count toward step therapy requirements. Document all previous therapies with dates, doses, and outcomes.

Q: What happens if my appeal is denied?
A: After exhausting UnitedHealthcare's internal appeals, you can request external review through Ohio's Department of Insurance. The external reviewer's decision is binding on UnitedHealthcare.

Q: How much does Rezlidhia cost without insurance?
A: List price is approximately $32,000 per month. The Rigel OneCare program provides free medication for eligible uninsured patients.

Sources & Further Reading

When facing insurance denials for critical cancer treatments like Rezlidhia, having the right strategy makes all the difference. Counterforce Health specializes in turning denials into approvals by crafting evidence-backed appeals that speak directly to each payer's specific criteria—helping patients get the treatments they need when they need them most.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For official appeals assistance in Ohio, contact the Department of Insurance at 1-800-686-1526.

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