By Counterforce Health Team in Tegsedi (inotersen) —

How to Get Tegsedi (inotersen) Covered by UnitedHealthcare in Texas: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Tegsedi (inotersen) Approved by UnitedHealthcare in Texas

Quick Path to Coverage: UnitedHealthcare requires prior authorization for Tegsedi (inotersen) for hereditary transthyretin amyloidosis with polyneuropathy. You'll need: (1) confirmed hATTR diagnosis with TTR mutation, (2) REMS program enrollment for patient, prescriber, and pharmacy, and (3) baseline labs showing platelets ≥100k and eGFR ≥45. Submit through the UHC Provider Portal with neurologist consultation and monitoring plan. Start today: Verify REMS enrollment status and gather genetic testing results.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Electronic Options
  4. Fax Numbers and Mailing Addresses
  5. REMS Program and Specialty Pharmacy Setup
  6. Support Lines and Who to Call
  7. Texas Appeals Process and External Review
  8. Update Schedule for Forms and Policies

Verify Your Plan and Find the Right Forms

Before starting your Tegsedi prior authorization, confirm your specific UnitedHealthcare plan type and current policy requirements.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Tegsedi prescriptions UHC PA Requirements UHC Policy
REMS Enrollment Patient, prescriber, pharmacy must be certified Tegsedi REMS Program FDA Mandate
Specialist Consultation Neurologist required PA Medical Necessity Form UHC Criteria
Baseline Labs Platelets ≥100k, eGFR ≥45 Same form Clinical Requirement
Genetic Testing Pathogenic TTR mutation confirmed Medical records Diagnosis Confirmation

Plan Type Verification Steps

  1. Check your UnitedHealthcare ID card for plan details
  2. Call the member services number on your card to confirm:
    • Whether Tegsedi requires prior authorization
    • Which specialty pharmacies are in-network
    • Your specific formulary tier for Tegsedi
  3. Access your member portal at myuhc.com to review pharmacy benefits
Tip: Self-funded employer plans may have different requirements than standard commercial plans. Always verify your specific coverage.

Prior Authorization Forms and Requirements

UnitedHealthcare uses two primary forms for Tegsedi prior authorization, depending on your plan type.

Form 1: Medical Necessity Prior Authorization

Download: PA Medical Necessity - Tegsedi

Required for: Commercial plans requiring full clinical review

Key sections to complete:

  • Patient demographics and insurance information
  • Diagnosis: hATTR amyloidosis with polyneuropathy
  • TTR mutation documentation
  • Baseline disease severity (PND score ≤IIIb or NIS 10-130)
  • Prescriber specialty (neurologist required)
  • REMS enrollment confirmation
  • Laboratory monitoring plan

Form 2: Prior Authorization Notification

Download: PA Notification - Tegsedi

Required for: Simplified notification programs

Streamlined requirements:

  • Basic diagnosis confirmation
  • TTR mutation present
  • No combination with other oligonucleotides
  • REMS compliance

Clinical Documentation Checklist

✅ Genetic testing results showing pathogenic TTR mutation
✅ Neurologist consultation notes
✅ Baseline laboratory results (within 30-60 days):

  • Complete blood count with platelets ≥100,000/µL
  • Comprehensive metabolic panel with eGFR ≥45 mL/min/1.73m²
  • Urinalysis with protein/creatinine ratio
  • Liver function tests
    ✅ Disease staging documentation (PND, FAP, or NIS scores)
    ✅ REMS enrollment confirmation for patient and prescriber
    ✅ Monitoring plan for weekly platelets and monthly renal function

Submission Portals and Electronic Options

UnitedHealthcare prioritizes electronic submissions for faster processing.

Primary Submission Methods

1. UnitedHealthcare Provider Portal (Preferred)

  • URL: UHCprovider.com
  • Access: Prior Authorization and Notification tool
  • Processing time: 5-7 business days standard
  • Covers: All Texas commercial plans

2. CoverMyMeds Integration

  • Platform: Electronic PA requests through CoverMyMeds
  • Processing: Fastest for non-urgent requests
  • Note: OptumRx partnership for streamlined submissions

3. OptumRx PreCheck Automation

  • Feature: Electronic prior authorization for select drugs
  • Speed: Median approval 29 seconds vs. 15-20 minutes manual
  • Status: Check if Tegsedi included via portal

Portal Setup Requirements

  • Provider NPI and Tax ID registration
  • Patient insurance verification
  • Secure document upload capability
  • Status tracking and notification preferences
Note: Starting August 1, 2025, UnitedHealthcare Community Plan in Texas requires electronic submissions for most appeals and reconsiderations.

Fax Numbers and Mailing Addresses

When electronic submission isn't available, use these backup methods.

UnitedHealthcare Fax Options

General Prior Authorization Fax: 1-844-403-1027

Cover Sheet Requirements:

  • Patient name and date of birth
  • UnitedHealthcare member ID
  • Provider name and NPI
  • Drug name: Tegsedi (inotersen)
  • Urgency level (standard or expedited)

Mailing Address

For paper submissions when required:

UnitedHealthcare
Prior Authorization Department
P.O. Box [verify current address with UHC]
[City, State ZIP - confirm via member services]
Important: Fax numbers and addresses can change. Always verify current contact information by calling the provider services number on your UnitedHealthcare ID card.

REMS Program and Specialty Pharmacy Setup

Tegsedi is only available through REMS-certified specialty pharmacies due to FDA safety requirements.

REMS Enrollment Steps

1. Prescriber Enrollment

  • Complete Tegsedi REMS training online
  • Obtain REMS certification number
  • Commit to monitoring requirements

2. Patient Enrollment

  • Sign monitoring agreement
  • Understand safety requirements
  • Receive REMS authorization

3. Pharmacy Certification

  • Verify REMS-certified specialty pharmacy
  • Common options: Optum Specialty Pharmacy, Accredo (verify network status)

UnitedHealthcare Specialty Pharmacy Network

Most UnitedHealthcare plans require specialty medications through designated pharmacies. Check the current Specialty Pharmacy Requirements for Tegsedi-approved pharmacies.

Transfer Process:

  1. Verify new pharmacy is UHC in-network and REMS-certified
  2. Update REMS enrollment with new pharmacy information
  3. Transfer prescription and PA approval
  4. Coordinate monitoring lab schedule continuity

Support Lines and Who to Call

UnitedHealthcare Contact Numbers

Member Services: Number on back of UHC ID card

  • Prior authorization status
  • Formulary verification
  • Appeals assistance

Provider Services: UHC Provider Line

  • PA submission help
  • Policy clarification
  • Technical portal support

UHC Web Support: 866-842-3278, option 1

  • Portal access issues
  • Electronic submission problems
  • Hours: 7 a.m.–9 p.m. CT, Monday–Friday

What to Ask When You Call

For PA Status: "I need to check the prior authorization status for Tegsedi (inotersen) for member [ID number]. Can you tell me if additional documentation is needed?"

For Denials: "My Tegsedi prior authorization was denied. Can you explain the specific reason and what documentation would address this denial?"

For Specialty Pharmacy: "Which REMS-certified specialty pharmacies are in-network for dispensing Tegsedi for this member?"

Texas Appeals Process and External Review

If your Tegsedi prior authorization is denied, Texas provides strong appeal rights.

UnitedHealthcare Internal Appeals

Level Deadline Timeline Submission Method
Internal Level 1 180 days from denial 30 days standard/72 hrs urgent UHC Provider Portal
Internal Level 2 60 days from Level 1 denial 30 days Same portal or mail

Texas External Review Options

After completing UHC internal appeals, Texas offers independent review:

Texas Department of Insurance (TDI) External Review

  • Phone: 866-554-4926 (IRO questions)
  • Deadline: 4 months from final UHC denial
  • Cost: Free to patient
  • Timeline: 20 days standard, 5 days urgent
  • Decision: Binding on UnitedHealthcare

Federal HHS External Review (for ACA marketplace plans)

  • Phone: 888-866-6205
  • Process: Similar timelines and procedures
  • Application: 4 months from final denial

Texas Consumer Assistance

Texas Department of Insurance

Office of Public Insurance Counsel (OPIC)

  • Phone: 877-611-6742
  • Services: Appeal assistance, consumer advocacy

Appeal Strategy for Tegsedi

Common denial reasons and responses:

  • Missing REMS enrollment: Provide updated certification documentation
  • Insufficient lab monitoring plan: Submit detailed weekly/monthly monitoring schedule
  • Specialist requirement: Add neurologist consultation and recommendation
  • Alternative therapy consideration: Document contraindications or failures with other hATTR treatments

Update Schedule for Forms and Policies

UnitedHealthcare updates prior authorization requirements periodically. Stay current with these practices:

Regular Check Points

Quarterly: Review current PA forms and requirements Annually: Verify specialty pharmacy network changes Policy updates: Monitor UHC provider communications for Tegsedi policy changes

Key Resources to Bookmark

Important: The manufacturer has discontinued commercial distribution of Tegsedi, but UnitedHealthcare maintains coverage criteria for existing patients. Verify current availability through 2025-2026.

From Our Advocates

We've seen Tegsedi approvals succeed when providers submit comprehensive REMS documentation upfront, including the monitoring plan and specialist consultation. The key is demonstrating both medical necessity and safety compliance in the initial submission, which can prevent denials and expedite approval.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Tegsedi. Our platform analyzes denial letters, identifies specific coverage gaps, and creates targeted appeals using UnitedHealthcare's own policy language and clinical evidence requirements. For patients facing Tegsedi denials in Texas, we help navigate both UnitedHealthcare's internal process and Texas external review options with documentation that meets regulatory standards.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Tegsedi in Texas? Standard processing is 5-7 business days through the provider portal. Urgent requests with physician documentation can be expedited to 24-72 hours.

What if Tegsedi isn't on my UnitedHealthcare formulary? Most UHC plans cover Tegsedi with prior authorization. If it's non-formulary, request a formulary exception with medical necessity documentation.

Can I request an expedited appeal in Texas? Yes, if delay would seriously jeopardize your health. Include a physician statement supporting urgency for 72-hour processing.

Does step therapy apply to Tegsedi with UnitedHealthcare? Current UHC criteria don't require step therapy with other hATTR treatments, but you cannot combine Tegsedi with other oligonucleotides.

What happens if my REMS enrollment expires? Tegsedi cannot be dispensed without active REMS status. Renew enrollment before expiration to avoid treatment interruption.

Disclaimer: This information is for educational purposes and doesn't constitute medical or legal advice. Coverage policies vary by plan and may change. Always verify current requirements with UnitedHealthcare and consult healthcare providers for medical decisions.

Sources & Further Reading

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