By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by UnitedHealthcare in Illinois: Complete Guide with Forms and Appeals

Answer Box: Getting Taltz Covered by UnitedHealthcare in Illinois

Quick Summary: UnitedHealthcare requires prior authorization for Taltz (ixekizumab) in Illinois with step therapy requirements. You must first try preferred biologics like Humira, Enbrel, or Cosentyx. Submit PA requests through the OptumRx portal or call 1-800-711-4555. If denied, you have 180 days for internal appeals and 120 days for Illinois external review through the Department of Insurance.

First step today: Check your UnitedHealthcare formulary status for Taltz and gather documentation of failed prior therapies.

Table of Contents

  1. Start Here: Verify Your Plan Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Step Therapy Requirements
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Illinois Members
  7. Specialty Pharmacy Setup
  8. Illinois External Review Process
  9. Cost-Saving Programs
  10. FAQ

Start Here: Verify Your Plan Coverage

Before starting the prior authorization process, confirm Taltz's status on your specific UnitedHealthcare plan. According to the 2025 Illinois Prescription Drug List, Taltz requires prior authorization and step therapy for most commercial plans.

What to check first:

  • Log into your myuhc.com account or call the number on your insurance card
  • Ask specifically about Taltz coverage, formulary tier, and step therapy requirements
  • Confirm if you need a specialist prescription (typically dermatologist for psoriasis)
  • Verify your specialty pharmacy network options

Prior Authorization Forms and Requirements

UnitedHealthcare processes Taltz prior authorizations through OptumRx. The specific requirements include:

Required Documentation

Document Type Details Source
PA Form OptumRx-specific Taltz form OptumRx Portal
Diagnosis Code ICD-10 for approved indication UHC PA Guide
Clinical Notes Treatment history and severity Provider records
TB Screening Recent negative test required Clinical documentation
Prior Therapy Records Failed/contraindicated treatments Medical records

Medical Necessity Criteria

According to UnitedHealthcare's medical necessity policy, Taltz approval requires:

  • Documented FDA-approved indication (moderate-to-severe plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, or non-radiographic axial spondyloarthritis)
  • Failure, contraindication, or intolerance to step therapy requirements
  • Negative tuberculosis screening within guidelines
  • Cannot be used in combination with other targeted immunomodulators
  • 12-month authorization period with annual renewal based on therapeutic response

Submission Portals and Methods

Primary Submission Methods

1. Online Portal (Recommended)

2. Phone Submission

  • Number: 1-800-711-4555
  • Available for follow-ups and status checks
  • Use when online portal is unavailable

3. Fax Submission

  • Check your denial letter for plan-specific fax numbers
  • Include cover sheet with member ID and drug name
  • Confirm receipt by calling member services

Step Therapy Requirements

UnitedHealthcare requires documented failure, contraindication, or intolerance to preferred biologics before approving Taltz. According to the Step Therapy Policy:

Required First-Line Therapies

  1. Adalimumab products (Humira or biosimilars)
  2. Etanercept (Enbrel)
  3. Secukinumab (Cosentyx)
  4. Ustekinumab (Stelara) - if designated as preferred on your plan

Documentation Requirements

For each failed therapy, provide:

  • Drug name, dosage, and duration of trial
  • Dates of treatment
  • Clinical response or reason for discontinuation
  • Adverse events or contraindications
  • Provider notes documenting inadequate response
Tip: Gather this documentation before submitting your PA request. Incomplete step therapy documentation is the most common reason for Taltz denials.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Incomplete step therapy Submit detailed prior therapy records Drug names, dates, outcomes, provider notes
Missing TB screening Provide recent negative TB test Lab results within required timeframe
Lack of specialist prescription Get dermatologist to prescribe/co-manage Specialist consultation notes
Insufficient diagnosis documentation Submit severity assessments PASI scores, clinical photos, impact measures
Combination therapy concern Confirm no concurrent immunomodulators Current medication list

Appeals Process for Illinois Members

If your initial prior authorization is denied, UnitedHealthcare provides multiple appeal levels:

Internal Appeals

Timeline: 180 days from denial date Submission Methods:

  • Online: UnitedHealthcare member portal with TrackIt tracking
  • Fax: 801-994-1261 (urgent appeals)
  • Mail: Member Grievance & Appeals, P.O. Box 31364, Salt Lake City, UT 84131-0364

Required Documents:

  • Copy of denial letter
  • Additional clinical documentation
  • Provider letter of medical necessity
  • Member ID and contact information

Peer-to-Peer Review

Request a peer-to-peer review where your prescribing physician speaks directly with a UnitedHealthcare medical director. This can often resolve denials without formal appeals.

Script for requesting peer-to-peer: "I'm requesting a peer-to-peer review for my patient's Taltz prior authorization denial. The patient has documented failure of step therapy requirements and meets all medical necessity criteria per your policy."

Specialty Pharmacy Setup

Taltz must be dispensed through UnitedHealthcare's specialty pharmacy network in Illinois.

Preferred Specialty Pharmacies

According to the Specialty Pharmacy Vendor List:

  • Optum Specialty Pharmacy (primary preferred)
  • Walgreens Specialty Pharmacy
  • Accredo Specialty Pharmacy

Enrollment Process

  1. Once PA is approved, your provider sends prescription to chosen specialty pharmacy
  2. Pharmacy contacts you for enrollment and insurance verification
  3. Complete patient intake forms and delivery preferences
  4. Schedule initial delivery and ongoing refills
  5. Enroll in manufacturer support programs if eligible

Illinois External Review Process

If UnitedHealthcare denies your internal appeal, Illinois law guarantees your right to an independent external review.

Key Illinois-Specific Details

  • Deadline: 120 days (4 months) from final adverse determination
  • Cost: Free to consumers
  • Timeline: Decision within 45 days (72 hours for urgent cases)
  • Authority: Illinois Department of Insurance

How to File External Review

  1. Get the form: Download the Request for External Review
  2. Submit via:
  3. Include: Denial letters, medical records, provider support letter

Illinois Consumer Assistance

The Illinois Department of Insurance can help you understand your rights and assist with filing appeals or external reviews.

Cost-Saving Programs

Manufacturer Support

Eli Lilly offers Taltz Support Services including:

  • Copay assistance (up to $25/month for eligible patients)
  • Patient support coordinators
  • Injection training and adherence support
  • Insurance navigation assistance

Additional Resources

  • Patient Advocate Foundation: Financial assistance for specialty medications
  • Illinois Prescription Drug Assistance Programs: State-specific support options
  • Manufacturer patient assistance programs: For uninsured or underinsured patients
From our advocates: "We've seen success when patients gather all their step therapy documentation upfront and work closely with their dermatologist's office to submit comprehensive PA requests. Having a specialist strongly advocate for medical necessity often makes the difference between approval and denial."

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by analyzing denial letters, identifying coverage gaps, and drafting evidence-backed rebuttals that align with each payer's specific requirements.

FAQ

How long does UnitedHealthcare PA take in Illinois? Standard prior authorizations typically take 15 business days. Urgent requests may be processed within 24-72 hours if medical urgency is documented.

What if Taltz is non-formulary on my plan? Non-formulary drugs require additional documentation and may have higher copays. Request a formulary exception with strong medical necessity justification.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Mark all submissions as "URGENT" and include physician certification of medical urgency.

Does step therapy apply if I failed treatments outside Illinois? Yes, documented treatment failures from any provider are acceptable. Ensure you have complete medical records showing drug names, dates, and outcomes.

What happens if my external review is approved? UnitedHealthcare must cover the treatment as ordered. The external review decision is binding and cannot be appealed by the insurance company.

How do I find my plan's specific formulary? Log into myuhc.com, call member services, or request your plan's current prescription drug list. Formularies are updated regularly.

When to Get Help

Consider contacting Counterforce Health or other advocacy services if:

  • Your initial PA is denied despite meeting step therapy requirements
  • You need help drafting a compelling medical necessity letter
  • Your appeal was denied and you're considering external review
  • You're facing complex coverage issues or multiple denials

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 your healthcare provider and insurance company for plan-specific guidance. For questions about your rights under Illinois insurance law, contact the Illinois Department of Insurance at 877-850-4740.

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