By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by UnitedHealthcare in Washington: Appeals, Prior Authorization & State Protections

Quick Answer: Getting Tysabri Covered in Washington

UnitedHealthcare requires prior authorization for Tysabri (natalizumab) through OptumRx before dispensing. You must be enrolled in the FDA-required TOUCH program and provide documentation of multiple sclerosis diagnosis with prior treatment failures. If denied, you have 180 days to file an internal appeal, followed by external review through Washington's Office of Insurance Commissioner. Start today: Have your neurologist submit a prior authorization request via the UnitedHealthcare provider portal at 888-397-8129, ensuring TOUCH enrollment is complete.

Table of Contents

  1. Why Washington State Rules Matter
  2. Prior Authorization Requirements
  3. Step Therapy Protections in Washington
  4. Appeals Process and Timelines
  5. External Review Through Washington OIC
  6. Common Denial Reasons & Solutions
  7. Practical Scripts and Templates
  8. Cost Assistance Programs
  9. When to Contact State Regulators
  10. FAQ

Why Washington State Rules Matter

Washington's insurance laws provide stronger consumer protections than many states, especially for specialty medications like Tysabri. The state requires insurers to follow specific timelines and provides robust external review rights through the Washington Office of Insurance Commissioner.

Understanding these protections is crucial because UnitedHealthcare operates different plan types in Washington—marketplace plans through Washington Healthplanfinder, Medicare Advantage plans, and employer-sponsored coverage—each with distinct appeal rights and timelines.

Note: Self-funded employer plans (ERISA) may not be subject to all Washington state protections, but many voluntarily follow similar procedures.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed
Prior Authorization Required before dispensing PA form via provider portal
TOUCH Program FDA safety enrollment Completed by prescriber
Medical Necessity Documented MS diagnosis ICD-10 code G35, MRI results
Step Therapy May require preferred alternatives first Prior treatment failures documented
Specialty Pharmacy Designated network required AllianceRx, Option Care, Optum Specialty

Medical Necessity Documentation

Your prescriber must submit comprehensive documentation including:

  • Diagnosis: Multiple sclerosis with ICD-10 code G35
  • Prior therapies: Complete history of disease-modifying treatments
  • Treatment failures: Documented inadequate response, intolerance, or contraindications to preferred alternatives
  • Clinical rationale: Why Tysabri is specifically needed for your condition
  • TOUCH enrollment: Confirmation of FDA safety program participation

Standard prior authorization requests typically take 72 hours, though some automated approvals can process in under 30 seconds for qualifying cases.

Step Therapy Protections in Washington

Washington's H.B. 1879 provides comprehensive step therapy protections that can help bypass requirements for preferred alternatives. Your health plan must grant an exception if:

  • Trying the preferred medication would create a significant barrier to compliance
  • The medication would worsen a comorbid condition
  • The medication is contraindicated for your specific situation
  • The medication will decrease your ability to achieve reasonable function

Requesting a Step Therapy Override

Work with your neurologist to document how alternative medications would:

  • Create barriers to treatment compliance
  • Worsen existing neurological or other conditions
  • Reduce your functional ability or quality of life

This documentation should reference Washington's specific exception criteria when submitting your prior authorization request.

Appeals Process and Timelines

Internal Appeals with UnitedHealthcare

Timeline Requirements:

  • Filing deadline: 180 days from initial denial
  • Standard review: 30 calendar days for decision
  • Expedited review: 72 hours if health is at serious risk
  • Acknowledgment: UnitedHealthcare must acknowledge within 5 days

How to Submit:

  • Phone: 1-877-542-8997
  • Fax: 1-801-994-1082
  • Mail: P.O. Box 31364, Salt Lake City, UT 84131-0364
  • Online: UnitedHealthcare member portal

Required Appeal Documentation

Include in your written appeal:

  • Direct response to each denial reason in your EOB
  • Updated clinical notes from your neurologist
  • Documentation of prior treatment failures from other states (if applicable)
  • References to FDA prescribing information
  • Current MS treatment guidelines supporting Tysabri use

External Review Through Washington OIC

If UnitedHealthcare denies your internal appeal, Washington provides free external review through Independent Review Organizations (IROs).

External Review Timeline

  • Filing deadline: 180 days from final internal denial
  • Standard review: 30 days for IRO decision
  • Expedited review: 72 hours for urgent cases
  • Cost: Free to you (insurer pays)
  • Decision: Binding on UnitedHealthcare

How to Request External Review

Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 to initiate the process. The OIC will assign an independent medical expert panel to review your case.

Required for IRO Review:

  • Copy of final internal denial letter
  • All medical records supporting your case
  • Written statement explaining why coverage should be approved
  • Any additional evidence you want the IRO to consider

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing TOUCH enrollment Confirm enrollment with Biogen at 1-800-456-2255
Inadequate MRI documentation Submit recent brain MRI showing MS lesions
Step therapy not completed Request exception citing Washington H.B. 1879 criteria
"Not medically necessary" Provide neurologist letter with treatment guidelines
Quantity limits exceeded Document medical need for specific dosing schedule

Peer-to-Peer Review Strategy

Request a peer-to-peer review with a UnitedHealthcare medical director. This allows your neurologist to directly discuss your case with their physician reviewer, often resolving denials without formal appeals.

Practical Scripts and Templates

Patient Phone Script for UnitedHealthcare

"I'm calling about a prior authorization denial for Tysabri, reference number [X]. I'd like to understand the specific denial reasons and request a peer-to-peer review between my neurologist and your medical director. Can you also confirm the deadline for filing an appeal and provide the fax number for medical records?"

Clinic Staff Script for Prior Authorization

"We're submitting a prior authorization for Tysabri for a patient with relapsing MS who has failed [specific medications]. The patient is enrolled in the TOUCH program. We're including documentation of prior treatment failures and current MRI results showing active disease. Please expedite if possible due to recent relapse activity."

Cost Assistance Programs

Even with UnitedHealthcare coverage, Tysabri costs can be significant. Available assistance includes:

  • Biogen Support Services: Copay assistance and financial counseling at 1-800-456-2255
  • Patient Access Network (PAN) Foundation: Grants for MS medications
  • HealthWell Foundation: Financial assistance for specialty drugs
  • Washington State pharmaceutical assistance programs: Income-based support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Tysabri. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with UnitedHealthcare's specific requirements, potentially saving weeks in the appeals process.

When to Contact State Regulators

Contact the Washington Office of Insurance Commissioner if:

  • UnitedHealthcare doesn't respond within required timelines
  • You believe the denial violates Washington insurance law
  • The appeals process isn't being followed correctly
  • You need help understanding your appeal rights

Washington OIC Consumer Advocacy: 1-800-562-6900 (Monday-Friday, 8 a.m. to 5 p.m.)

The OIC provides free specialized assistance with complex medication appeals and can help file complaints if your plan violates required procedures.

From Our Advocates: We've seen cases where patients successfully overturned Tysabri denials by clearly documenting how step therapy alternatives worsened their MS symptoms or created compliance barriers. The key is connecting your specific medical situation to Washington's step therapy exception criteria—this gives your appeal stronger legal grounding than general medical necessity arguments alone.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Washington? Standard requests take 72 hours, though some automated approvals process in under 30 seconds. Expedited requests for urgent cases are decided within 72 hours.

What if Tysabri is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Focus on why preferred alternatives are unsuitable for your specific condition.

Can I request an expedited appeal? Yes, if a medical provider believes delay could seriously jeopardize your health or subject you to severe pain. Expedited appeals are decided within 72 hours.

Does step therapy apply if I failed treatments in another state? Yes, document all prior treatment failures regardless of where they occurred. Include medical records showing inadequate response or intolerance.

What happens if the external review overturns the denial? UnitedHealthcare must authorize coverage and process payment. The IRO decision is legally binding on the insurer.

Do I need a specialty pharmacy for Tysabri? Yes, UnitedHealthcare requires designated specialty pharmacies including AllianceRx Walgreens, Option Care Health, and Optum Specialty Pharmacy unless an exception is granted.

How do I know if my plan is subject to Washington state protections? Marketplace plans and fully-insured employer plans follow Washington laws. Self-funded employer plans (ERISA) may have different procedures, though many voluntarily follow similar processes.

Can Counterforce Health help with my Tysabri appeal? Counterforce Health specializes in analyzing denial letters and drafting evidence-backed appeals for specialty medications, including those requiring TOUCH program enrollment like Tysabri.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact the Washington Office of Insurance Commissioner for specific guidance about your appeal rights. Insurance policies and state regulations may change; verify current requirements with official sources.

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