By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (osimertinib) Covered by UnitedHealthcare in California: Prior Authorization, Appeals & Cost Assistance

Answer Box: Getting Tagrisso Covered by UnitedHealthcare in California

Quick answer: Tagrisso requires prior authorization from UnitedHealthcare but has $0 copay for covered patients. To get approved: (1) Submit PA with EGFR mutation test results through your doctor, (2) If denied, file internal appeal within 180 days, (3) Request California DMHC Independent Medical Review if still denied. Success rates are high with proper documentation. Start by having your oncologist gather your EGFR mutation pathology report and submit the prior authorization through UnitedHealthcare's provider portal.

Table of Contents

What Drives Tagrisso Coverage Costs

Understanding UnitedHealthcare's benefit design helps you navigate the approval process more effectively. Tagrisso (osimertinib) sits on Tier 3 of OptumRx's formulary for 2024, which typically means higher cost-sharing—but California law provides important protection.

The good news: Under current regulations, oral anti-cancer medications like Tagrisso have no copay or cost sharing ($0 out-of-pocket) for covered UnitedHealthcare members. This applies once your prior authorization is approved.

Coverage barriers you'll encounter:

  • Prior authorization requirement (mandatory for all members)
  • Specialty pharmacy restriction (must use Optum Specialty Pharmacy)
  • Medical necessity documentation (EGFR mutation testing required)
  • Quantity limits (typically one tablet per day)
Note: Your specific plan may have different requirements. Always verify with your member services before starting treatment.

Investigating Your UnitedHealthcare Benefits

Before your doctor submits a prior authorization, gather this information by calling UnitedHealthcare Member Services or checking your online account:

Essential questions to ask:

  1. "Is Tagrisso covered on my formulary, and what tier?"
  2. "What's my copay for Tier 3 specialty medications?"
  3. "Do I need prior authorization for Tagrisso?"
  4. "Which pharmacy network must I use?"
  5. "Are there quantity limits or step therapy requirements?"

Information to record:

  • Your member ID and group number
  • Prior authorization submission method (provider portal vs. fax)
  • Required forms or documentation
  • Processing timeline (typically 15 business days)
  • Appeal deadlines and procedures

Contact UnitedHealthcare Member Services at the number on your insurance card, or access your account through the UnitedHealthcare mobile app.

Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Tagrisso, with specific clinical criteria that must be documented. Here's what your oncologist needs to submit:

Required Documentation

Diagnosis confirmation:

  • Pathologically confirmed non-small cell lung cancer (NSCLC)
  • Stage documentation (metastatic, locally advanced, or adjuvant setting)
  • ICD-10 codes for NSCLC

EGFR mutation evidence:

  • Laboratory report showing positive EGFR mutation from FDA-approved testing
  • Specific mutations covered: exon 19 deletion, L858R, T790M, S768I, L861Q, G719X
  • Test methodology and date of analysis

Treatment rationale:

  • Line of therapy (first-line, post-progression, adjuvant)
  • Prior treatments attempted (if applicable)
  • Clinical goals and expected outcomes

Submission Process

Your oncologist should submit the prior authorization through the UnitedHealthcare Provider Portal with all required documentation attached. Processing typically takes up to 15 business days, though urgent cases may qualify for expedited review within 72 hours.

Tip: Ask your doctor's office to request expedited review if you have aggressive disease or are experiencing progression on current therapy.

Assistance Programs and Cost Support

Even with UnitedHealthcare's $0 copay for oral cancer drugs, you may face costs during prior authorization delays or coverage gaps.

AstraZeneca Patient Support

Tagrisso Co-pay Savings Program:

  • Available for commercially insured patients (including UnitedHealthcare)
  • May reduce out-of-pocket costs to $0 (subject to program terms)
  • No published income limits for commercial insurance
  • Enroll at MyAccess360.com or call 844-275-2360

AZ&Me Prescription Savings Program:

  • For uninsured patients or those with government insurance
  • Income-based eligibility requirements
  • Apply at AZandMeApp.com

Additional Support Resources

California-specific assistance:

  • Health Consumer Alliance (consumer advocacy)
  • Legal aid organizations for complex appeals
  • Cancer support organizations with financial assistance programs

When navigating coverage challenges, platforms like Counterforce Health help patients and providers turn insurance denials into targeted appeals by analyzing denial letters, plan policies, and clinical notes to draft evidence-backed rebuttals aligned with payer requirements.

Pharmacy Requirements and Coordination

UnitedHealthcare restricts Tagrisso dispensing to their specialty pharmacy network, which requires coordination between your doctor, the pharmacy, and your insurance.

Optum Specialty Pharmacy Requirements

Mandatory network:

  • All Tagrisso prescriptions must go through Optum Specialty Pharmacy
  • Both mail order and retail coordination available
  • Cannot use standard retail pharmacies for initial fills

Setting up service:

  • Your doctor sends the prescription directly to Optum Specialty Pharmacy
  • Call 855-427-4682 to set up your account
  • Have your UnitedHealthcare member ID ready
  • Choose mail delivery or retail pickup coordination

What to expect:

  • Pharmacist consultation on first fill
  • Automatic refill coordination
  • Side effect monitoring and support
  • Direct insurance billing (no upfront payment typically required)
Note: Using non-network pharmacies will result in claim denials and out-of-pocket costs.

Appeals Process in California

If UnitedHealthcare denies your Tagrisso prior authorization, California provides robust appeal rights through both internal insurance company processes and state oversight.

Step 1: Internal Appeal with UnitedHealthcare

Timeline: File within 180 days of denial Process:

  • Submit through UnitedHealthcare member portal or by mail
  • Include denial letter, medical records, and prescriber's appeal letter
  • Standard review: 30 days; Expedited: 72 hours for urgent cases

Required documentation:

  • Original prior authorization request
  • EGFR mutation pathology report
  • Oncologist's medical necessity letter
  • Relevant clinical guidelines (NCCN, FDA labeling)

Step 2: California DMHC Independent Medical Review

If UnitedHealthcare upholds the denial, California residents can request an Independent Medical Review (IMR) through the Department of Managed Health Care.

Key advantages:

  • No cost to patient
  • Binding decision - UnitedHealthcare must comply within 5 working days
  • High success rates for medically necessary specialty drugs
  • Independent physician experts review your case

How to file:

  • Online at healthhelp.ca.gov
  • Call DMHC Help Center: 888-466-2219
  • Must file within 6 months of final internal denial

Timeline:

  • Standard IMR: 45 days maximum
  • Expedited IMR: 7 days (often within 72 hours for urgent cases)

California's enforcement data shows that insurers face substantial penalties for failing to properly handle appeals, with recent actions ranging from $10,000 to $550,000 for grievance and appeal violations.

Annual Renewal and Planning

What can change year to year:

  • Formulary tier placement
  • Prior authorization requirements
  • Copay amounts (though oral cancer drug protections typically continue)
  • Pharmacy network restrictions
  • Quantity limits

Planning ahead:

  • Review your plan's Summary of Benefits each open enrollment
  • Confirm Tagrisso remains covered before switching plans
  • Budget for potential coverage gaps during plan transitions
  • Maintain current prescriptions through December if changing plans
Tip: If you're stable on Tagrisso, avoid changing insurance plans unnecessarily, as you'll need to restart the prior authorization process.

Conversation Scripts

Calling UnitedHealthcare Member Services

"Hi, I'm calling about prior authorization requirements for Tagrisso, generic name osimertinib, for my lung cancer treatment. My member ID is [number]. Can you tell me:

  • Is this medication covered on my plan?
  • What documentation does my doctor need to submit?
  • How long does the prior authorization process take?
  • What's my copay once it's approved?"

Provider Office - Requesting Expedited Review

"My patient has EGFR-positive NSCLC and needs Tagrisso urgently due to disease progression. Please submit an expedited prior authorization request and include:

  • The EGFR mutation pathology report
  • Current imaging showing progression
  • Medical necessity letter explaining urgency
  • Request 72-hour expedited review due to clinical urgency"

Pharmacy Coordination Script

"I'm setting up Tagrisso through Optum Specialty Pharmacy for UnitedHealthcare coverage. My prescription should be coming from [doctor's office]. Can you:

  • Confirm you've received the prescription?
  • Verify my insurance benefits?
  • Set up mail delivery to my address?
  • Explain the refill process and timeline?"

FAQ

How long does UnitedHealthcare prior authorization take for Tagrisso? Standard processing is up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours. Your doctor can request expedited review if you have progressive disease.

What if Tagrisso is denied as "not medically necessary"? File an internal appeal with comprehensive clinical documentation, then request a California DMHC Independent Medical Review if still denied. Success rates are high with proper EGFR mutation documentation and oncologist support.

Can I use GoodRx or other discount programs with UnitedHealthcare? No, you cannot combine insurance coverage with discount programs. However, AstraZeneca's patient assistance programs can work alongside your insurance to reduce any remaining costs.

Does step therapy apply to Tagrisso in California? UnitedHealthcare may require step therapy, but exceptions are available if other EGFR inhibitors failed or are contraindicated. Your oncologist can request an exception with clinical justification.

What happens if I move out of California? Your UnitedHealthcare coverage continues, but you'll lose access to California's DMHC Independent Medical Review process. Check your new state's external review rights and timelines.

How much does Tagrisso cost without insurance? List prices typically exceed $15,000 per 30-day supply. This is why insurance coverage and patient assistance programs are crucial for access.

For complex cases involving multiple denials or unusual circumstances, specialized services like Counterforce Health can help analyze your specific situation and develop targeted appeal strategies that align with UnitedHealthcare's coverage policies.

Sources & Further Reading

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 personalized guidance. For additional support with California insurance appeals, contact the DMHC Help Center at 888-466-2219.

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