By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (osimertinib) Covered by UnitedHealthcare in Georgia: Prior Authorization Guide, Appeal Steps, and External Review

Answer Box: Getting Tagrisso Covered by UnitedHealthcare in Georgia

UnitedHealthcare requires prior authorization for Tagrisso (osimertinib) in Georgia. To get approval: (1) Submit documented proof of EGFR mutation-positive NSCLC, (2) Complete the UnitedHealthcare PA form with clinical notes showing disease stage and treatment history, (3) If denied, file internal appeal within 180 days, then external review with Georgia DOI within 60 days of final denial. Start by gathering your EGFR mutation test results and contacting your oncologist today to begin the PA submission through UnitedHealthcare's provider portal.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Tagrisso prescriptions UnitedHealthcare Provider Portal UHC PA Form
EGFR Mutation Must document exon 19 deletion, L858R, T790M, or other qualifying mutations Lab report from FDA-approved testing UHC PA Requirements
Disease Stage Stage IB-IV NSCLC with specific treatment contexts Pathology/imaging reports UHC Clinical Criteria
Internal Appeal Deadline 180 days from denial notice Denial letter UHC Appeals Process
External Review Deadline 60 days from final internal denial Georgia DOI Georgia External Review

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: Patient and care team
What you need: EGFR mutation test results, pathology report, staging information, prior treatment history
Timeline: 1-2 days
Source: UnitedHealthcare PA Requirements

2. Complete Prior Authorization Form

Who does it: Prescribing oncologist or clinic staff
What's needed: UnitedHealthcare Tagrisso PA form with all clinical documentation attached
How to submit: UnitedHealthcare Provider Portal or fax
Timeline: Same day submission possible

3. Submit Medical Necessity Letter

Who does it: Oncologist
What to include: Diagnosis, EGFR mutation type, disease stage, prior treatments, clinical rationale
Timeline: 1-2 business days to prepare

4. Track Approval Status

Who does it: Patient or clinic
How: UnitedHealthcare member portal or provider portal
Expected response: 72 hours for standard requests, 24 hours for expedited
Source: UHC Provider Portal

5. If Denied, Request Peer-to-Peer Review

Who does it: Prescribing oncologist
Timeline: Within 7-14 days of denial
Process: Direct discussion with UnitedHealthcare medical director

6. File Internal Appeal if Needed

Who does it: Patient or authorized representative
Deadline: 180 days from denial
How: UnitedHealthcare appeals process online or by mail
Source: UHC Appeals

7. Request Georgia External Review

Who does it: Patient
Deadline: 60 days from final internal denial
How: Georgia Department of Insurance at 1-800-656-2298
Cost: Free for patients

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No EGFR mutation documented Submit FDA-approved lab results Molecular pathology report specifying mutation type
Step therapy not completed Request medical exception Prior treatment history, adverse events, contraindications
Wrong clinical setting Clarify indication Staging data, treatment plan, oncologist letter
Quantity limits exceeded Justify dosing NCCN guidelines, dosing calculation, clinical rationale
Not medically necessary Submit comprehensive appeal Medical necessity letter, peer-reviewed studies, guidelines
From Our Advocates: We've seen denials overturned when oncologists include specific language about why step therapy would be harmful—for example, documenting that delays in targeted therapy for EGFR-positive NSCLC can lead to disease progression and reduced treatment options. This clinical urgency argument, backed by NCCN guidelines, often succeeds in appeals.

Appeals Playbook for UnitedHealthcare in Georgia

Internal Appeal Process

  • Level 1: Submit within 180 days of denial
  • Decision timeline: 30 days for standard, 72 hours for expedited
  • How to file: UnitedHealthcare member portal, provider portal, or mail
  • Required documents: Original denial letter, medical records, prescriber letter

Peer-to-Peer Review

  • When to request: Within 7-14 days of denial
  • Process: Oncologist speaks directly with UnitedHealthcare medical director
  • Preparation: Have all clinical data, guidelines, and patient-specific factors ready
  • Success factors: Clear articulation of medical necessity and guideline support

External Review in Georgia

  • Eligibility: After completing internal appeals process
  • Deadline: 60 days from final internal denial
  • Cost: Free for patients
  • Process: Independent review organization examines case
  • Decision timeline: 30-45 days standard, 72 hours expedited
  • Contact: Georgia Department of Insurance at 1-800-656-2298
  • Website: Georgia DOI

Medical Necessity Letter: What Your Oncologist Needs

Your oncologist's medical necessity letter should include:

Patient Information:

  • Full name, date of birth, medical record number
  • Diagnosis: Non-small cell lung cancer with histology
  • EGFR mutation status (specific type: exon 19 deletion, L858R, T790M, etc.)

Clinical Justification:

  • Cancer stage and treatment setting (adjuvant, metastatic, recurrent)
  • Prior therapies and responses
  • FDA indication being requested
  • NCCN guideline support
  • Patient-specific factors (contraindications, prior failures)

Treatment Plan:

  • Tagrisso 80mg daily
  • Duration requested
  • Monitoring plan
  • Expected clinical benefits

Supporting Evidence:

  • EGFR mutation test results
  • Pathology reports
  • Prior treatment records
  • Relevant imaging or lab results

When to Request Peer-to-Peer Review

Request a peer-to-peer review when:

  • Initial PA is denied despite meeting criteria
  • Clinical urgency requires immediate treatment
  • Complex case requires physician-to-physician discussion
  • Step therapy exceptions are needed

How to prepare:

  • Schedule within 7-14 days of denial
  • Have all clinical documentation ready
  • Prepare talking points about medical necessity
  • Reference specific NCCN guidelines and FDA labeling

Georgia External Review Process

If your internal appeals with UnitedHealthcare fail, Georgia law provides an independent external review process:

Eligibility Requirements

  • Must complete UnitedHealthcare's internal appeal process first
  • Denial must be based on medical necessity, not contractual exclusions
  • Applies to fully insured plans (not self-funded employer plans)

Filing Process

  1. Contact Georgia DOI: Call 1-800-656-2298 within 60 days of final denial
  2. Submit application: Complete external review request form
  3. Provide documentation: Include all denial letters, medical records, and appeals
  4. Independent review: Qualified physicians review your case
  5. Final decision: Binding on UnitedHealthcare if in your favor

Timeline

  • Standard review: 30-45 days
  • Expedited review: 72 hours for urgent medical situations
  • Cost: Free for patients

For assistance with the external review process, contact:

  • Georgia DOI Consumer Services: 1-800-656-2298
  • Georgians for a Healthy Future: Patient advocacy organization

Cost Savings and Patient Support

Even with insurance coverage, Tagrisso can have significant out-of-pocket costs. Consider these options:

AstraZeneca Patient Support

  • AZ&Me Prescription Savings Program: Copay assistance for eligible patients
  • Patient Access Network Foundation: Grants for cancer patients
  • Eligibility: Income and insurance requirements apply
  • Contact: 1-800-292-6363

Additional Resources

  • CancerCare Financial Assistance: Grants and copay help
  • Leukemia & Lymphoma Society: Patient aid program
  • State pharmaceutical assistance: Georgia may have programs for residents

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Georgia?

Standard PA requests receive decisions within 72 hours. Expedited requests for urgent medical situations are processed within 24 hours.

What if Tagrisso is non-formulary on my plan?

You can request a formulary exception through the prior authorization process. Your oncologist will need to provide medical necessity documentation explaining why Tagrisso is required over formulary alternatives.

Can I request an expedited appeal?

Yes, if your medical situation is urgent and delays would jeopardize your health. Cancer treatments often qualify for expedited review, which provides decisions within 72 hours.

Does step therapy apply if I've failed treatments outside Georgia?

Treatment history from any location should count toward step therapy requirements. Provide complete documentation of prior therapies and their outcomes regardless of where treatment occurred.

What happens if my employer plan is self-funded?

Self-funded plans may not be subject to Georgia's external review process. Contact your HR department about the plan's appeal procedures, which may include federal external review options.

How do I know if my EGFR mutation qualifies?

UnitedHealthcare covers Tagrisso for EGFR mutations including exon 19 deletions, exon 21 L858R substitutions, T790M, S768I, L861Q, and G719X. Your mutation test report should specify the exact mutation type.

Can I start treatment while the appeal is pending?

This depends on your clinical situation and financial resources. Discuss with your oncologist about urgent treatment needs and consider patient assistance programs for temporary coverage.

What if I miss the 60-day deadline for external review?

Georgia's 60-day deadline is strict. If you miss it, you may lose the right to external review. Contact the Georgia DOI immediately if you're approaching the deadline or have extenuating circumstances.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to craft targeted, evidence-backed responses. The platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes, ensuring that medically necessary treatments like Tagrisso get the coverage they deserve. Learn more at www.counterforcehealth.org.

For complex denials or when you need expert assistance with your Tagrisso appeal, Counterforce Health can help analyze your specific situation and develop a comprehensive appeal strategy tailored to UnitedHealthcare's requirements and Georgia's regulatory framework.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical situation and treatment options. Insurance coverage policies may change, and individual circumstances vary. Verify current requirements with UnitedHealthcare and the Georgia Department of Insurance before taking action.

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