By Counterforce Health Team in Rezlidhia (olutasidenib) —

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

Quick Answer: Getting Rezlidhia Covered in Texas

UnitedHealthcare requires prior authorization for Rezlidhia (olutasidenib) in Texas. To get approved, you'll need documented IDH1 mutation testing, confirmed relapsed/refractory AML diagnosis, and evidence of failed prior therapies. Submit through the UnitedHealthcare Provider Portal with complete medical necessity documentation. If denied, you have 180 days to appeal internally, followed by external review through Texas's Independent Review Organization system. Start today by gathering your IDH1 test results and treatment history.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding and Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: Tracking Your Request
  9. Common Denial Reasons & How to Avoid Them
  10. Appeals Process in Texas
  11. Cost and Financial Assistance
  12. Frequently Asked Questions

Who Should Use This Guide

This guide is for patients diagnosed with relapsed or refractory acute myeloid leukemia (AML) with an IDH1 mutation who need Rezlidhia (olutasidenib) covered by UnitedHealthcare in Texas. You'll also find this helpful if you're a healthcare provider submitting prior authorization requests or appealing denials.

Expected outcome: Following this process typically results in approval within 7-15 business days for complete submissions. If denied initially, proper appeals have strong success rates when documentation is thorough.

Member & Plan Basics

Coverage Verification

Before starting, confirm your UnitedHealthcare plan covers specialty medications:

  • Commercial plans: Most require prior authorization for Rezlidhia
  • Medicare Advantage: Subject to Part D formulary restrictions and prior authorization
  • Medicaid managed care: Varies by state contract; check with your plan
Tip: Call the member services number on your insurance card to verify your pharmacy benefits include specialty drug coverage.

Key Plan Information to Gather

  • Policy/member ID number
  • Group number (if employer-sponsored)
  • Effective dates of coverage
  • Deductible and out-of-pocket maximum
  • Specialty pharmacy network requirements

Clinical Criteria for Approval

UnitedHealthcare requires specific clinical documentation for Rezlidhia approval:

FDA-Approved Indication

Rezlidhia is approved for adults with relapsed or refractory AML with a susceptible IDH1 mutation, as detected by an FDA-approved test.

Required Clinical Criteria

Requirement Documentation Needed Source
AML diagnosis Pathology report, bone marrow biopsy Medical records
IDH1 mutation FDA-approved assay results Laboratory report
Relapsed/refractory status Treatment history, response assessment Oncology notes
Prior therapy failure Detailed treatment summary Complete medical history
Prescriber qualification Board-certified hematologist/oncologist Provider credentials

Step Therapy Requirements

UnitedHealthcare typically requires documented failure or intolerance to:

  • Ivosidenib (Tibsovo) - preferred IDH1 inhibitor
  • Standard AML regimens such as venetoclax + azacitidine
  • Alternative therapies appropriate for patient's condition

Coding and Billing Requirements

Diagnosis Codes (ICD-10)

  • C92.00 - Acute myeloblastic leukemia, not having achieved remission
  • C92.02 - Acute myeloblastic leukemia, in relapse
  • Z87.891 - Personal history of nicotine dependence (if applicable)

Drug Codes

Code Type Code Description
NDC 71332-005-01 Rezlidhia 150mg capsules, 30-count
HCPCS J3490 Unclassified drugs (temporary)
HCPCS J9999 Miscellaneous antineoplastic drugs
Note: Rezlidhia doesn't have a permanent J-code yet. Use the miscellaneous codes above and verify current requirements with UnitedHealthcare.

Documentation Packet

Medical Necessity Letter Components

Your oncologist's letter must include:

  1. Patient identification - Full name, DOB, member ID
  2. Diagnosis confirmation - AML type, staging, date of diagnosis
  3. IDH1 mutation details - Specific mutation, test method, laboratory
  4. Treatment history - All prior therapies, dates, outcomes, reasons for discontinuation
  5. Clinical rationale - Why Rezlidhia is medically necessary
  6. Monitoring plan - Safety protocols for differentiation syndrome
  7. Guideline support - NCCN or FDA labeling references

Required Attachments

  • IDH1 mutation test report (complete laboratory document)
  • Pathology report confirming AML diagnosis
  • Complete treatment history with dates and outcomes
  • Recent clinic notes documenting current disease status
  • Bone marrow biopsy results (if recent)

Submission Process

Step-by-Step Submission

  1. Gather documentation (allow 2-3 days for medical records)
  2. Complete PA form via UnitedHealthcare Provider Portal
  3. Upload all attachments in PDF format
  4. Submit request and record confirmation number
  5. Track status daily through provider portal
  6. Respond promptly to any requests for additional information

Submission Timelines

  • Standard review: 7-15 business days
  • Expedited review: 2-3 business days (for urgent cases)
  • Additional information requests: 3-5 business days to respond

Specialty Pharmacy Requirements

Rezlidhia requires dispensing through UnitedHealthcare's specialty pharmacy network:

Preferred Specialty Pharmacies

  • Optum Specialty Pharmacy
  • Biologics by McKesson
  • Optime Care

Transfer Process

  1. After PA approval, contact assigned specialty pharmacy
  2. Provide insurance information and prescription details
  3. Coordinate delivery (typically 2-3 business days)
  4. Verify receipt and proper storage instructions

After Submission: Tracking Your Request

What to Monitor

  • Confirmation number from initial submission
  • Status updates through provider portal
  • Requests for additional information
  • Approval or denial notification

Expected Communication

UnitedHealthcare will send:

  • Email confirmation of submission
  • Status updates during review
  • Final determination letter
  • Appeal rights information (if denied)

Common Denial Reasons & How to Avoid Them

Denial Reason How to Prevent Required Documentation
Missing IDH1 mutation Submit complete lab report FDA-approved assay results
Incomplete treatment history Provide detailed therapy summary All prior treatments with dates/outcomes
Non-specialist prescriber Ensure oncologist involvement Board-certified hematologist/oncologist
Missing safety plan Include monitoring protocols Differentiation syndrome management plan
Insufficient medical necessity Strengthen clinical rationale Reference guidelines and FDA labeling

Appeals Process in Texas

Internal Appeals

If your initial request is denied:

Step 1: Reconsideration (UnitedHealthcare)

  • Timeline: Submit within 180 days of denial
  • Decision timeframe: 60 days for post-service appeals
  • Expedited option: 72 hours for urgent cases
  • Submission: UnitedHealthcare Provider Portal

External Review (Texas IRO)

After exhausting internal appeals:

Independent Review Organization Process

  • Timeline: Request within 45 days of final internal denial
  • Decision timeframe: 20 days for standard review, 8 days for life-threatening conditions
  • Cost: Paid by UnitedHealthcare
  • Binding decision: Insurer must comply if overturned

Texas Department of Insurance Support

At Counterforce Health, we help patients and clinicians navigate complex insurance appeals by turning denials into targeted, evidence-backed rebuttals. Our platform analyzes denial letters and crafts point-by-point appeals aligned to each payer's specific requirements, significantly improving approval rates for specialty medications like Rezlidhia.

Cost and Financial Assistance

Manufacturer Support

  • Rigel Patient Support Program - Copay assistance and prior authorization support
  • Financial counseling available through specialty pharmacies

Additional Resources

  • Patient Advocate Foundation - Copay relief programs
  • CancerCare - Financial assistance for cancer patients
  • State pharmaceutical assistance programs (varies by income)

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Texas? Standard review takes 7-15 business days. Expedited review for urgent cases can be completed within 72 hours.

What if Rezlidhia is non-formulary on my plan? Non-formulary drugs can still be covered through prior authorization with strong medical necessity documentation and evidence of failed preferred alternatives.

Can I request an expedited appeal? Yes, expedited appeals are available for urgent medical situations and must be decided within 72 hours by UnitedHealthcare.

Does step therapy apply if I failed treatments outside Texas? Yes, documented treatment failures from any location count toward step therapy requirements, provided you have complete medical records.

What happens if my appeal is denied? You can request external review through Texas's Independent Review Organization system, which provides a binding decision.

Who can prescribe Rezlidhia? The prescriber must be a board-certified hematologist/oncologist. Primary care physicians typically cannot obtain approval for this specialty medication.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance requirements and processes may change. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, consider services like Counterforce Health that specialize in turning prescription drug denials into successful appeals.

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