By Counterforce Health Team in Tavneos (avacopan) —

How to Get Tavneos (Avacopan) Covered by UnitedHealthcare in Texas: Complete Guide with Forms, Appeals, and Templates

Answer Box: Getting Tavneos Covered by UnitedHealthcare in Texas

UnitedHealthcare requires prior authorization for Tavneos (avacopan) in Texas. Your fastest path to approval: Have your rheumatologist, nephrologist, or pulmonologist submit a prior authorization through the UnitedHealthcare Provider Portal with documented severe active ANCA-associated vasculitis (GPA or MPA) and confirmation that Tavneos will be used alongside standard therapy like rituximab or cyclophosphamide. Start today: Call UnitedHealthcare at 866-889-8054 to verify your plan's formulary status and request the current PA form. If denied, Texas law guarantees you the right to internal appeals and an Independent Review Organization (IRO) external review.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Forms and Documentation
  4. Submission Portals and Contact Information
  5. Medical Necessity Letter Template
  6. Common Denial Reasons and How to Fix Them
  7. Texas Appeals Process
  8. Specialty Pharmacy Network
  9. Financial Assistance Options
  10. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Tavneos prescriptions UHC PA Requirements
Diagnosis Severe active GPA or MPA with ANCA confirmation Medical records, lab results
Prescriber Rheumatologist, nephrologist, pulmonologist, or vascular medicine specialist Provider credentials
Combination Therapy Must be used WITH standard therapy (rituximab/cyclophosphamide + steroids) Treatment plan documentation
Initial Authorization Valid for 6 months UHC policy
Reauthorization Valid for 12 months if stable Clinical progress notes

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage

Who does it: You or your clinic
What's needed: UnitedHealthcare member ID
How to submit: Call 866-889-8054 or log into member portal
Timeline: Immediate

2. Gather Required Documentation

Who does it: Your specialist and clinic staff
What's needed:

  • ANCA-positive lab results
  • Biopsy reports (if available)
  • Documentation of GPA or MPA diagnosis
  • Prior therapy history and outcomes
  • Current treatment plan showing combination therapy

Timeline: 1-2 days

3. Complete Prior Authorization Request

Who does it: Your prescribing specialist
What's needed: UHC Tavneos PA form
How to submit: UnitedHealthcare Provider Portal or fax to designated number
Timeline: Submit within 24-48 hours of gathering docs

4. Submit Medical Necessity Letter

Who does it: Your specialist
What's needed: Detailed clinical justification (see template below)
How to submit: Attach to PA request
Timeline: Same day as PA submission

5. Follow Up on Decision

Who does it: You or clinic staff
Timeline: UHC has 15 business days to respond
Next step: If approved, coordinate with specialty pharmacy. If denied, proceed to appeals.

Required Forms and Documentation

Primary Forms

  • UnitedHealthcare Tavneos Prior Authorization Form: Available through the Provider Portal
  • Medical Necessity Letter: Custom letter from your specialist (template below)

Supporting Documentation Checklist

  • ANCA antibody test results (positive c-ANCA/PR3 or p-ANCA/MPO)
  • Tissue biopsy report (if performed)
  • Complete medical history with organ involvement documentation
  • Birmingham Vasculitis Activity Score (BVAS) if available
  • Prior therapy records showing trials with cyclophosphamide, rituximab, or steroids
  • Current treatment plan confirming combination therapy approach
  • Recent lab work (CBC, CMP, liver function tests)
Tip: UnitedHealthcare specifically requires documentation that Tavneos will be used in addition to, not instead of, standard immunosuppressive therapy.

Submission Portals and Contact Information

Online Submission

  • Provider Portal: UnitedHealthcare Provider Portal
  • Member Portal: Available for status checks and document uploads
  • Electronic PA: Supported through OptumRx e-PA system

Phone and Fax

  • Prior Authorization Phone: 866-889-8054
  • Appeals Fax: 1-855-405-2189 (verify current number on denial letter)
  • Mailing Address: UnitedHealthcare Claims Appeals
    PO Box 30432
    Salt Lake City, UT 84130-0432

Specialty Pharmacy Support

Medical Necessity Letter Template

[Date]

UnitedHealthcare Medical Director
Prior Authorization Department
[Address from denial letter or PA form]

Re: Prior Authorization Request for Tavneos (avacopan)
Patient: [Full Name], DOB: [Date], Member ID: [UHC ID]
ICD-10: M31.30 (GPA) or M31.7 (MPA)

Dear Medical Director,

I am writing as the treating [rheumatologist/nephrologist/pulmonologist] for [Patient Name] to request coverage of Tavneos (avacopan) for the treatment of severe, active ANCA-associated vasculitis.

DIAGNOSIS AND CLINICAL PRESENTATION:
[Patient Name] has confirmed [Granulomatosis with Polyangiitis/Microscopic Polyangiitis] based on:
- Positive ANCA serology: [specify c-ANCA/PR3 or p-ANCA/MPO with titers]
- Clinical manifestations: [list organ involvement - kidney, lung, upper respiratory tract, etc.]
- [Include biopsy results if available]
- Current disease activity score: [BVAS if available]

TREATMENT HISTORY:
The patient has been treated with standard therapies including:
- [List prior medications with dates, doses, duration, and outcomes]
- [Document any treatment failures, inadequate responses, or intolerances]

MEDICAL NECESSITY FOR TAVNEOS:
Tavneos is FDA-approved for adjunctive treatment of severe active ANCA-associated vasculitis in combination with standard immunosuppressive therapy. For this patient, Tavneos is medically necessary because:
- [Specific clinical rationale for this patient]
- [Expected benefits: steroid-sparing effects, improved organ preservation]
- [Risk-benefit analysis specific to this case]

TREATMENT PLAN:
Tavneos 30mg twice daily will be used IN COMBINATION WITH:
- [Current immunosuppressive regimen - rituximab/cyclophosphamide]
- [Corticosteroid plan]
- [Monitoring schedule for safety and efficacy]

This combination approach aligns with FDA labeling and current treatment guidelines for ANCA-associated vasculitis.

Please contact me at [phone] if you need additional information. I am available for peer-to-peer review at your convenience.

Sincerely,
[Name], MD
[Specialty]
[NPI Number]

Attachments: Medical records, lab results, prior therapy documentation

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not prescribed by specialist" Confirm prescriber credentials Board certification, NPI verification
"Diagnosis not documented" Submit comprehensive records ANCA results, biopsy, clinical notes
"Not adjunctive therapy" Clarify treatment plan Letter confirming combination approach
"Prior therapy not documented" Provide complete history Pharmacy records, clinic notes, dates
"Quantity limits exceeded" Justify dosing FDA labeling, clinical rationale
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing the specific denial basis and crafting point-by-point rebuttals aligned to each plan's requirements.

Texas Appeals Process

Internal Appeals with UnitedHealthcare

Level 1: Reconsideration

  • Deadline: 180 days from denial
  • Timeline: UHC responds within 30 days (pre-service) or 60 days (post-service)
  • Submit to: Provider Portal or fax 1-855-405-2189

Level 2: Internal Appeal

  • Deadline: After reconsideration denial
  • Timeline: 30-60 days for UHC response
  • Requirements: Detailed clinical justification, peer-to-peer review available

External Review (Texas IRO)

When to File: After exhausting internal appeals

  • Deadline: 4 months from final internal denial
  • Timeline: 20 days for standard review, 5 days for expedited
  • Cost: Free to patient (UHC pays IRO fees)
  • Outcome: Binding decision

Texas Department of Insurance Contact:

  • Phone: 1-800-252-3439
  • IRO Information: 1-866-554-4926

Expedited Appeals

For urgent situations where delay could jeopardize health:

  • Internal expedited: 72 hours
  • External expedited: 5 days
  • Can run concurrent with standard appeals

Specialty Pharmacy Network

Tavneos is available through UnitedHealthcare's limited specialty pharmacy network:

Primary Network Pharmacy: PANTHERx Rare Pharmacy

  • Enrollment: Required before first fill
  • Transfer Process: New prescription from specialist to PANTHERx
  • Support: Available through Tavneos patient support program
Important: Accredo is not an in-network pharmacy for Tavneos under UnitedHealthcare. Attempting to fill at non-network pharmacies will result in coverage denial.

Financial Assistance Options

Manufacturer Support

  • Tavneos Copay Program: Available for eligible commercially insured patients
  • Patient Assistance: For uninsured or underinsured patients
  • Information: TavneosPro.com financial assistance

Foundation Grants

  • Patient Advocate Foundation: Copay relief for chronic conditions
  • HealthWell Foundation: Disease-specific grants
  • Good Days: Rare disease financial assistance

When navigating complex insurance approvals, Counterforce Health helps patients and clinicians by analyzing denial letters and crafting targeted appeals that address specific payer requirements with the right clinical evidence and procedural approach.

FAQ

How long does UnitedHealthcare prior authorization take for Tavneos in Texas? UnitedHealthcare has 15 business days to respond to prior authorization requests. Expedited reviews for urgent cases are completed within 72 hours.

What if Tavneos is not on my UnitedHealthcare formulary? Even non-formulary drugs can be covered through the prior authorization process with strong medical necessity documentation. Appeal rights apply if initially denied.

Can I request an expedited appeal if my condition is worsening? Yes. Texas allows expedited internal and external appeals when delays could jeopardize your health. Both can run simultaneously.

Does step therapy apply to Tavneos? UnitedHealthcare requires documentation of prior therapy attempts, but formal step therapy may not apply given Tavneos's unique mechanism and combination therapy requirement.

What happens if my appeal is denied in Texas? You have the right to an Independent Review Organization (IRO) external review through the Texas Department of Insurance. This decision is binding on UnitedHealthcare.

How much does Tavneos cost without insurance? Retail pricing is approximately $17,000 per month. Annual costs can reach $170,000-$210,000, making insurance coverage critical.

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 plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional support with insurance appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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