By Counterforce Health Team in Tavneos (avacopan) —

How to Get Tavneos (Avacopan) Covered by UnitedHealthcare in Michigan: Prior Authorization Forms, Appeal Process & Medical Necessity Letters

Answer Box: Getting Tavneos Covered by UnitedHealthcare in Michigan

Eligibility: Tavneos (avacopan) requires prior authorization from UnitedHealthcare for severe active ANCA-associated vasculitis (GPA/MPA) when used alongside standard therapy like rituximab or cyclophosphamide. Fastest path: Submit a complete PA request through the UnitedHealthcare provider portal with specialist documentation, ANCA test results, and proof of combination therapy. First step today: Contact your rheumatologist, nephrologist, or pulmonologist to gather diagnosis documentation (ICD-10 codes M31.31 for GPA or M31.7 for MPA) and current treatment records. If denied, Michigan patients have 127 days to file an external review with Michigan DIFS.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. If You Need to Provide More Information
  7. If Your Request Is Denied
  8. Appeals Process in Michigan
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This guide helps Michigan patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Tavneos (avacopan), a specialized medication for ANCA-associated vasculitis. Whether you're dealing with your first PA request or appealing a denial, we'll walk you through each step with specific forms, deadlines, and requirements for Michigan residents.

Tavneos costs approximately $17,000 per month, making prior authorization almost universal across insurance plans. However, with proper documentation and persistence, many patients successfully obtain coverage.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Tavneos. Their platform analyzes denial letters and creates point-by-point rebuttals aligned with each payer's specific requirements, helping patients and providers navigate these challenging approval processes more effectively.

Before You Start: Verify Your Coverage

Check Your Plan Type

UnitedHealthcare operates several plan types in Michigan, each with different processes:

  • Commercial/Employer plans: Standard PA through OptumRx
  • Medicare Advantage: May have additional CMS requirements
  • Medicaid managed care: Different appeal timelines apply

Confirm Formulary Status

Log into your UnitedHealthcare member portal or call the number on your insurance card to verify:

  • Tavneos formulary tier (typically specialty tier)
  • Your specific copay or coinsurance
  • Whether step therapy applies to your plan

Verify Network Status

Ensure your prescribing specialist is in-network. UnitedHealthcare requires Tavneos to be prescribed by:

  • Rheumatologist
  • Nephrologist
  • Pulmonologist
  • Vascular medicine specialist

Gather Required Documentation

Essential Medical Records

Diagnosis Documentation:

  • ANCA test results (PR3-ANCA for GPA, MPO-ANCA for MPA)
  • ICD-10 codes: M31.31 (GPA) or M31.7 (MPA)
  • Biopsy results if available
  • Imaging studies showing organ involvement

Current Treatment Records:

  • Documentation of standard therapy (rituximab, cyclophosphamide, or other immunosuppressants)
  • Current glucocorticoid regimen
  • Treatment response or lack thereof
  • Side effects from current medications

Required Lab Values

  • Complete blood count (CBC)
  • Comprehensive metabolic panel (CMP)
  • Liver function tests (critical for Tavneos safety monitoring)
  • Urinalysis
  • ESR and CRP levels

Prior Authorization Forms

Access the current UnitedHealthcare PA form for Tavneos through:

Submit Your Prior Authorization Request

UnitedHealthcare's Specific Requirements

Based on their official policy, UnitedHealthcare requires:

  1. Severe active ANCA-associated vasculitis diagnosis (GPA or MPA)
  2. Adjunctive use with standard immunosuppressive therapy
  3. Specialist prescriber (rheumatology, nephrology, or pulmonology)
  4. Quantity limit compliance (180 capsules per 30 days)

Clean Request Packet Checklist

✓ Completed PA form with all sections filled ✓ Prescriber's DEA and NPI numbers ✓ Patient's UnitedHealthcare member ID ✓ Detailed diagnosis with ICD-10 codes ✓ ANCA test results and titers ✓ Current medication list with doses ✓ Documentation of combination therapy plan ✓ Specialist's clinical notes supporting medical necessity

Submission Methods

Electronic (fastest): UnitedHealthcare provider portal with electronic PA capability Fax: Submit to OptumRx PA department (verify current fax number through portal) Mail: Only if electronic options aren't available

Follow-Up and Timeline Expectations

Standard Timelines

  • Commercial plans: 15 calendar days for standard review
  • Urgent requests: 72 hours if medical urgency documented
  • Medicare Advantage: May have different CMS-mandated timelines

When to Call

Contact UnitedHealthcare if:

  • No response after 10 business days
  • Request additional information
  • Status shows "pending" beyond normal timeframes

Sample Call Script: "I'm calling to check the status of a prior authorization request for Tavneos for my patient [name], member ID [number]. The request was submitted on [date]. Can you provide the current status and any additional requirements?"

Document all calls with:

  • Date and time
  • Representative name
  • Reference numbers provided
  • Next steps discussed

If You Need to Provide More Information

Common Medical Necessity Questions

UnitedHealthcare may request clarification on:

  • Why Tavneos is being used adjunctively vs. as monotherapy
  • Specific organ systems involved in the vasculitis
  • Response to previous treatments
  • Hepatic function status (due to Tavneos liver toxicity risk)

Supporting Literature

Include evidence from:

  • FDA prescribing information
  • ACR/EULAR guidelines for ANCA-associated vasculitis
  • Peer-reviewed studies on Tavneos efficacy
  • Specialty society treatment recommendations

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason Solution
"Not for adjunctive use" Provide documentation of concurrent immunosuppressive therapy
"Prescriber not specialist" Transfer prescription to in-network rheumatologist/nephrologist
"Diagnosis not supported" Submit complete ANCA test results and biopsy reports
"Step therapy required" Document failure/intolerance of required first-line treatments

Peer-to-Peer Review

Request a peer-to-peer discussion with UnitedHealthcare's medical director:

  • Must be conducted within one business day of request
  • Reviewing physician must have expertise in vasculitis treatment
  • Decision typically made at end of discussion or within 24 hours

Appeals Process in Michigan

Internal Appeals (First Step)

Timeline: File within 180 days of denial Process:

  1. Submit appeal through UnitedHealthcare member portal
  2. Include denial letter and additional supporting documentation
  3. Request expedited review if medically urgent

External Review Through Michigan DIFS

If internal appeals are unsuccessful:

Timeline: 127 days from final internal denial to file with Michigan DIFS

Expedited Process:

  • 72 hours for urgent medical situations
  • Requires physician letter documenting urgency
  • Must file within 10 calendar days of denial

Required Documents:

  • Final denial letter from UnitedHealthcare
  • Completed DIFS external review form
  • Medical records supporting necessity
  • Physician attestation for expedited requests

Contact: Michigan DIFS at 877-999-6442 (Mon-Fri, 8am-5pm)

From our advocates: We've seen Michigan patients successfully overturn Tavneos denials by ensuring their rheumatologist clearly documents the adjunctive use requirement in clinical notes. The key is showing UnitedHealthcare that Tavneos isn't replacing standard therapy but enhancing it. This distinction often makes the difference in approval decisions.

Renewal and Reauthorization

Initial Authorization Duration

  • 6 months for first approval
  • 12 months for subsequent renewals

Renewal Requirements

  • Continued specialist involvement
  • Documentation of clinical benefit
  • Absence of progressive disease
  • Ongoing combination with standard therapy
  • Updated liver function tests

Calendar Reminders

Set reminders 45 days before expiration to begin renewal process, allowing time for any additional documentation requests.

Quick Reference Checklist

Before Submitting PA: □ Verify specialist is in-network □ Confirm diagnosis codes (M31.31 or M31.7) □ Document ANCA test results □ List current immunosuppressive medications □ Check liver function tests are current

Required Documentation: □ Completed UnitedHealthcare PA form □ Specialist's clinical notes □ ANCA serology results □ Proof of combination therapy □ Patient's UnitedHealthcare member ID

If Denied: □ Review denial reason carefully □ Request peer-to-peer if appropriate □ File internal appeal within 180 days □ Consider Michigan DIFS external review (127-day deadline) □ Contact Counterforce Health for appeal assistance

FAQ

How long does UnitedHealthcare PA take in Michigan? Standard requests: 15 calendar days. Urgent requests with physician documentation: 72 hours.

What if Tavneos is non-formulary on my plan? Non-formulary medications can still be covered through medical necessity appeals. Focus on documenting lack of formulary alternatives and unique clinical benefits.

Can I request an expedited appeal in Michigan? Yes, Michigan offers 72-hour expedited external reviews through DIFS for urgent medical situations with physician attestation.

Does step therapy apply to Tavneos? UnitedHealthcare may require trial of standard vasculitis treatments first. Document any failures or contraindications to bypass step therapy.

What's the difference between internal and external appeals? Internal appeals are handled by UnitedHealthcare directly. External appeals in Michigan go through DIFS with independent medical reviewers.

How much does Tavneos cost without insurance? Approximately $17,000 per month. Amgen offers patient assistance programs - check Tavneos.com for eligibility.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan directly for coverage determinations. Coverage policies and requirements may change; verify current information with UnitedHealthcare and Michigan DIFS before proceeding.

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