By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by UnitedHealthcare in Michigan: Appeals, Copay Programs & Prior Authorization

Quick Answer: Getting Tysabri Covered by UnitedHealthcare in Michigan

UnitedHealthcare requires prior authorization for Tysabri (natalizumab) through their Provider Portal or by calling 888-397-8129. If denied, you have internal appeal rights followed by Michigan DIFS external review within 127 days. First step today: Have your doctor submit a prior authorization request with complete medical necessity documentation, including failed prior therapies and TOUCH program enrollment. Commercial patients may qualify for Biogen's copay assistance program (up to $3,250 annually).

Table of Contents

  1. What Drives Tysabri Costs with UnitedHealthcare
  2. Investigating Your Benefits
  3. Copay Assistance and Financial Support
  4. Requesting Tier Exceptions
  5. Specialty Pharmacy Requirements
  6. Appeals Process in Michigan
  7. Annual Renewal Planning
  8. Scripts for Key Conversations

What Drives Tysabri Costs with UnitedHealthcare

Understanding your UnitedHealthcare plan's benefit design helps predict and manage Tysabri costs. Here's what influences your out-of-pocket expenses:

Specialty Tier Placement

Tysabri typically sits on UnitedHealthcare's specialty tier, which carries the highest cost-sharing. For 2025, Medicare Part D members benefit from a new $2,000 annual out-of-pocket maximum, but commercial plan members face variable cost-sharing without this federal cap.

Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Tysabri through OptumRx. Recent policy changes in 2025 have increased utilization management for specialty medications, including multiple sclerosis treatments.

Note: OptumRx announced in March 2025 that they're eliminating reauthorizations for approximately 80 drugs, potentially reducing some administrative burden for established patients.

Specialty Pharmacy Network

UnitedHealthcare mandates that outpatient providers obtain Tysabri from designated specialty pharmacies including AllianceRx Walgreens Pharmacy, Amber Specialty Pharmacy, Option Care Health, and Optum Specialty Pharmacy, unless an exception is granted.

Investigating Your Benefits

Before starting the approval process, gather this essential information:

Key Questions for UnitedHealthcare

  • Is Tysabri on my plan's formulary? What tier?
  • What's my specialty drug deductible and coinsurance?
  • Do I have an annual out-of-pocket maximum?
  • Which specialty pharmacies are in-network for Tysabri?
  • Are there step therapy requirements?

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before prescribing UnitedHealthcare Provider Portal UHC PA Requirements
Specialty Tier Higher cost-sharing than generic/brand drugs Plan formulary document Plan-specific formulary
TOUCH Enrollment FDA-required safety program participation Biogen Support Services TOUCH Program
Designated Pharmacy Must use approved specialty pharmacies UHC Admin Drug Chart Specialty Network

Copay Assistance and Financial Support

Biogen Copay Assistance Program

Commercial UnitedHealthcare members may qualify for significant cost reduction through Biogen's copay program:

Eligibility Requirements:

  • Commercial/private insurance (not Medicare or Medicaid)
  • US or Puerto Rico resident, 18+ years old
  • NOT available in Massachusetts or Rhode Island
  • FDA-approved indication for Tysabri

2025 Benefits:

  • Up to $250 per administration
  • Annual maximum of $3,250 per calendar year
  • Covers administration costs only (not office visits or drug cost)
  • No income requirements
Tip: Enroll online at the Biogen Copay Program website or call 800-456-2255. The program pays providers directly, and caps reset each January 1st.

Additional Financial Resources

  • Biogen Support Services: Comprehensive patient support including insurance navigation
  • National MS Society: Potential emergency financial assistance
  • Patient Advocate Foundation: Co-Pay Relief Program for chronic conditions

Requesting Tier Exceptions

If Tysabri is non-formulary or on a high-cost tier, you can request a formulary exception through UnitedHealthcare.

Medical Necessity Documentation Requirements

Your prescriber must submit documentation addressing why preferred formulary alternatives are:

  • Not as effective for your condition, OR
  • Would cause adverse effects, OR
  • Both of the above

Essential Documentation:

  • Diagnosis with ICD-10 codes (multiple sclerosis: G35)
  • Complete history of prior disease-modifying therapies
  • Documented failures, intolerances, or contraindications to preferred alternatives
  • Clinical rationale for natalizumab specifically
  • Relevant lab results, MRI findings, or disability assessments

Submission Process

  • Submit via UnitedHealthcare Provider Portal or written request
  • Include all supporting medical records
  • UnitedHealthcare typically responds within 72 hours (standard) or 24 hours (expedited)
  • If denied, appeal rights and external review options will be provided

Specialty Pharmacy Requirements

UnitedHealthcare's Designated Network

For outpatient Tysabri administration, UnitedHealthcare requires use of these specialty pharmacies:

  • AllianceRx Walgreens Pharmacy
  • Amber Specialty Pharmacy
  • Option Care Health
  • Optum Specialty Pharmacy
  • AleraCare
  • FloMed Infusion Services
  • Metro Infusion Center
Important: The pharmacy bills UnitedHealthcare directly for the medication under your medical benefit. Your provider bills separately only for administration services.

Coordination Tips

  • Confirm your infusion center works with UnitedHealthcare's designated pharmacies
  • Verify the pharmacy can coordinate with your TOUCH program requirements
  • Ask about delivery timing to ensure no treatment delays
  • Keep documentation of all pharmacy communications for appeals if needed

Appeals Process in Michigan

Michigan residents have strong appeal rights under the Patient's Right to Independent Review Act when UnitedHealthcare denies Tysabri coverage.

Internal Appeals with UnitedHealthcare

Timeline:

  • 30 days for pre-service denials
  • 60 days for post-service denials
  • File promptly after receiving written denial

Required Documentation:

  • Original denial letter
  • Complete medical records supporting necessity
  • Prescriber's detailed medical necessity letter
  • Documentation of failed prior therapies

Michigan DIFS External Review

If UnitedHealthcare's internal appeal is unsuccessful, you have 127 days from the final denial to request external review through Michigan's Department of Insurance and Financial Services (DIFS).

Process:

  1. Complete DIFS Health Care Request for External Review form
  2. Include final denial letter and supporting medical documentation
  3. Submit online, by mail, fax, or email to DIFS
  4. DIFS assigns case to Independent Review Organization (IRO)
  5. Decision within 60 days (or 72 hours for expedited review)

Contact DIFS: 877-999-6442 for forms and guidance

Expedited Review: Available for urgent pre-service denials when delay would harm patient health. Requires supporting letter from physician.

Annual Renewal Planning

What Changes Each Year

  • Formulary placement and tier assignments
  • Prior authorization requirements
  • Specialty pharmacy network
  • Cost-sharing amounts (deductible, coinsurance)
  • Copay assistance program caps reset

Renewal Checklist

  • Review new formulary documents in October-November
  • Confirm Tysabri remains covered at current tier
  • Re-enroll in Biogen copay assistance program
  • Update TOUCH program information if needed
  • Schedule early prior authorization renewal if required

Budget Planning: For Medicare Part D, remember the new $2,000 annual cap starting in 2025. Commercial plans don't have this federal protection, so budget based on your specific plan's out-of-pocket maximum.

Scripts for Key Conversations

Calling UnitedHealthcare Member Services

"Hi, I'm calling about prior authorization requirements for Tysabri, which is natalizumab. My member ID is [number]. Can you tell me:

  • Is this medication on my plan's formulary and what tier?
  • What's the prior authorization process?
  • What's my specialty drug cost-sharing?
  • Which specialty pharmacies are in-network for this medication?"

Requesting Peer-to-Peer Review

"I'm requesting a peer-to-peer review for my patient's Tysabri denial. The patient has relapsing MS with documented failure of [specific prior therapies]. The denial was based on [reason from letter]. When can we schedule the clinical discussion with your medical director?"

Specialty Pharmacy Coordination

"I need to coordinate Tysabri delivery for a UnitedHealthcare patient. Can you confirm:

  • You're contracted with UnitedHealthcare for this medication?
  • You can coordinate with the TOUCH program requirements?
  • What's your typical delivery timeline?
  • Do you handle the prior authorization directly with the plan?"

When to Get Additional Help

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters, plan policies, and clinical notes to identify the denial basis and draft point-by-point rebuttals aligned to UnitedHealthcare's own rules. For complex Tysabri denials involving multiple prior therapies or challenging medical necessity arguments, professional appeal assistance can significantly improve approval odds.

Escalation Resources

  • Michigan DIFS Consumer Hotline: 877-999-6442
  • UnitedHealthcare Member Services: Number on your insurance card
  • Biogen Support Services: 800-456-2255
  • National MS Society: 1-800-344-4867

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take for Tysabri? A: Standard requests typically take 72 hours, though UnitedHealthcare has implemented automated systems that can process some approvals in under 30 seconds for qualifying cases.

Q: What if Tysabri isn't on my UnitedHealthcare formulary? A: Request a formulary exception with medical necessity documentation. Your doctor must explain why preferred alternatives aren't suitable for your condition.

Q: Can I appeal a denial if I live in Michigan? A: Yes. You have internal appeal rights with UnitedHealthcare, followed by external review through Michigan DIFS within 127 days of final denial.

Q: Does the Biogen copay program work with UnitedHealthcare? A: Yes, if you have commercial UnitedHealthcare coverage (not Medicare or Medicaid). The program provides up to $3,250 annually toward administration costs.

Q: What's considered medical necessity for Tysabri? A: Diagnosis of relapsing MS or Crohn's disease, documented failure or intolerance of preferred alternatives, and enrollment in the TOUCH safety program.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and requirements may change. For the most current information, contact UnitedHealthcare directly or visit their provider website.

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