By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by UnitedHealthcare in Washington: Prior Authorization Guide & Appeal Steps

Answer Box: Getting Tagrisso Covered by UnitedHealthcare in Washington

You can get Tagrisso (osimertinib) covered by UnitedHealthcare in Washington if you have EGFR-mutated non-small cell lung cancer (NSCLC) and meet prior authorization criteria. The fastest path: ensure your oncologist has documented EGFR mutation test results (exon 19 deletion or L858R), complete UnitedHealthcare's prior authorization through their provider portal, and be prepared for step therapy requirements. If denied, Washington's external review process through an Independent Review Organization (IRO) provides strong patient protections with binding decisions within 15-20 days for standard cases or 72 hours for urgent situations.

First step today: Contact your oncologist to confirm EGFR mutation testing is complete and request they initiate the prior authorization process through UnitedHealthcare's provider portal.

Table of Contents

  1. Quick Eligibility Check
  2. UnitedHealthcare Prior Authorization Requirements
  3. Step Therapy and Formulary Requirements
  4. Fastest Path to Approval: 7 Steps
  5. Common Denial Reasons & How to Fix Them
  6. Appeals Process in Washington
  7. External Review (IRO) Process
  8. Cost and Financial Assistance
  9. FAQ
  10. Sources & Further Reading

Quick Eligibility Check

Use this decision tree to determine your likelihood of coverage:

✅ Likely Eligible if you have ALL of these:

  • Confirmed NSCLC diagnosis (metastatic or adjuvant setting)
  • Positive EGFR mutation (exon 19 deletion, L858R, T790M, S768I, L861Q, or G719X)
  • FDA-approved test results documented in medical records
  • UnitedHealthcare commercial plan with prescription drug coverage

⚠️ Possibly Eligible (may need additional steps):

  • NSCLC diagnosis but EGFR testing pending or incomplete
  • Previous treatment with other EGFR inhibitors (erlotinib, gefitinib, afatinib)
  • Medicare Advantage or employer plan with different formulary

❌ Not Yet Eligible:

  • No confirmed EGFR mutation
  • NSCLC without documented progression on standard therapy
  • Plan doesn't cover specialty medications

UnitedHealthcare Prior Authorization Requirements

UnitedHealthcare requires prior authorization for all Tagrisso prescriptions through OptumRx specialty pharmacy. Here's what you need:

Coverage Requirements Table

Requirement Details Documentation Needed
Prior Authorization Mandatory for all plans Complete PA form via provider portal
EGFR Mutation FDA-approved test required Lab report with specific mutation type
Diagnosis NSCLC with staging Pathology report, ICD-10 codes
Pharmacy OptumRx Specialty Must use designated specialty pharmacy
Review Time Up to 15 business days 72 hours for urgent requests
Reauthorization Annual renewal Clinical response documentation

Required Documentation Checklist

Before your provider submits the prior authorization:

  • Pathology report confirming NSCLC diagnosis
  • EGFR mutation test results from FDA-approved assay
  • Disease staging information (metastatic vs. adjuvant)
  • Treatment history including prior therapies and outcomes
  • Clinical rationale for Tagrisso over alternatives
  • Patient insurance information and pharmacy preference
Clinician Corner: Medical necessity letters should reference the specific EGFR mutation type, prior treatment failures or contraindications to first-line agents, and cite relevant guidelines from NCCN or ASCO. Include dosing rationale and monitoring plan.

Step Therapy and Formulary Requirements

UnitedHealthcare classifies Tagrisso as a specialty medication subject to step therapy rules. This means you may need to try preferred alternatives first unless exceptions apply.

Preferred First-Line EGFR Inhibitors

  • Erlotinib (Tarceva)
  • Gefitinib (Iressa)
  • Afatinib (Gilotrif)

Step Therapy Exceptions

Your doctor can request to bypass step therapy if you have:

  • Contraindications to preferred agents
  • Previous intolerance or severe adverse reactions
  • T790M resistance mutation (Tagrisso is preferred)
  • Clinical urgency where delay could harm your health

Counterforce Health specializes in helping patients and providers navigate these complex prior authorization requirements, turning insurance denials into targeted, evidence-backed appeals that align with each plan's specific criteria.

Fastest Path to Approval: 7 Steps

  1. Confirm EGFR Testing (Patient + Oncologist)
    • Ensure FDA-approved EGFR mutation test is complete
    • Verify results show actionable mutation
    • Timeline: 7-14 days for test results
  2. Gather Documentation (Clinic Staff)
    • Collect pathology reports, staging studies, treatment history
    • Prepare clinical rationale for Tagrisso
    • Timeline: 1-2 days
  3. Submit Prior Authorization (Provider)
    • Use UnitedHealthcare Provider Portal
    • Include all required documentation
    • Timeline: Same day submission possible
  4. OptumRx Specialty Enrollment (Patient)
    • Contact OptumRx to set up specialty pharmacy services
    • Provide insurance and shipping information
    • Timeline: 24-48 hours
  5. Track PA Status (Patient + Provider)
    • Monitor through provider portal or member services
    • Follow up if additional information requested
    • Timeline: Up to 15 business days
  6. Handle Step Therapy (Provider, if applicable)
    • Submit exception request with clinical justification
    • Document contraindications or prior failures
    • Timeline: Additional 5-10 business days
  7. Coordinate Delivery (Patient + Pharmacy)
    • Confirm shipping address and timing
    • Review medication instructions and side effects
    • Timeline: 2-3 days after approval

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No EGFR mutation documented Submit FDA-approved test results Lab report with mutation type
Step therapy not completed Request exception with clinical justification Prior treatment records, contraindications
Wrong treatment setting Clarify metastatic vs. adjuvant indication Staging studies, treatment intent
Quantity limits exceeded Provide dosing rationale Weight-based calculations, clinical guidelines
Non-formulary status Request formulary exception Medical necessity letter, alternative failures

Appeals Process in Washington

If your initial prior authorization is denied, Washington provides strong patient protections through a structured appeals process.

Internal Appeals (UnitedHealthcare)

First-Level Internal Appeal:

  • Timeline: 180 days from denial to file
  • Process: Submit written appeal with additional clinical evidence
  • Decision: Within 30 days (15 days for urgent cases)
  • How to file: UnitedHealthcare member portal or written request

Peer-to-Peer Review:

  • Request within 7-14 days of denial
  • Direct physician-to-physician discussion
  • Often resolves coverage disputes quickly
  • Contact UnitedHealthcare provider services to schedule

When Internal Appeals Fail

If UnitedHealthcare upholds the denial after internal appeals, Washington residents can proceed to external review—a powerful tool that removes the decision from the insurance company.

External Review (IRO) Process

Washington's Independent Review Organization (IRO) process provides binding external review of insurance denials, governed by RCW 48.43.535.

Timeline and Process

Review Type Timeline When to Use
Standard Review 15-20 days Most denials after internal appeals
Expedited Review 72 hours Life-threatening situations, urgent cancer treatment
Self-Insured Plans 45 days Employer ERISA plans (federal oversight)

How to Request External Review

  1. File Request: Submit to UnitedHealthcare or directly to Washington Office of Insurance Commissioner
  2. Carrier Response: UnitedHealthcare must send all records to IRO within 3 business days
  3. Your Input: You have 5 business days to submit additional evidence to IRO
  4. IRO Decision: Independent medical specialists review case and issue binding decision
  5. Outcome: If IRO overturns denial, UnitedHealthcare must provide coverage
Note: IRO decisions are binding on insurance companies. If the IRO determines Tagrisso is medically necessary, UnitedHealthcare must approve coverage.

Contact Information

  • Washington Office of Insurance Commissioner: 1-800-562-6900
  • Appeals guidance: Available at insurance.wa.gov with template letters and step-by-step instructions

The platform at Counterforce Health can help prepare comprehensive appeals by identifying the specific denial basis and crafting point-by-point rebuttals that align with UnitedHealthcare's own coverage policies and Washington state requirements.

Cost and Financial Assistance

Even with insurance coverage, Tagrisso can involve significant out-of-pocket costs. Here are assistance options:

Manufacturer Support

  • AstraZeneca Patient Assistance Program: Income-based free drug program
  • Tagrisso Co-pay Card: May reduce copays for eligible commercial patients
  • Information: Available through AstraZeneca's patient support website

Foundation Grants

  • Patient Advocate Foundation: Co-pay relief for cancer medications
  • CancerCare Financial Assistance: Grants for treatment-related costs
  • Leukemia & Lymphoma Society: Patient aid program

State Resources

  • Washington Apple Health (Medicaid): May cover Tagrisso for eligible patients
  • Washington State Prescription Drug Program: Additional assistance options

FAQ

How long does UnitedHealthcare prior authorization take in Washington? Standard review takes up to 15 business days. Urgent requests for life-threatening conditions can be expedited to 72 hours. Track status through the UnitedHealthcare provider or member portal.

What if Tagrisso is non-formulary on my plan? Request a formulary exception by documenting medical necessity and failure/contraindication of formulary alternatives. Your oncologist should provide clinical justification for why Tagrisso is uniquely appropriate.

Can I request an expedited appeal if my cancer is progressing? Yes. Washington allows expedited external review for urgent medical situations. Document how delays could seriously jeopardize your health and request 72-hour review timeline.

Does step therapy apply if I've tried other EGFR inhibitors outside Washington? Prior treatment history from other states should count toward step therapy requirements. Ensure your provider includes complete treatment records in the prior authorization submission.

What happens if the IRO upholds UnitedHealthcare's denial? IRO decisions are final for the insurance appeals process. You may still pursue legal action or seek alternative coverage options, but the administrative appeals process is complete.

How do I know if my plan is self-insured (ERISA)? Check your insurance card or contact HR. Self-insured employer plans follow federal ERISA rules rather than Washington state insurance law, though many voluntarily use similar external review processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances, plan details, and medical necessity. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For personalized assistance with prior authorizations and appeals, consider consulting with coverage advocacy services that specialize in insurance navigation.

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