By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (Ravulizumab) Covered by UnitedHealthcare in Ohio: Prior Authorization, Appeals, and Step Therapy Override Guide

Answer Box: Getting Ultomiris Approved by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Ultomiris (ravulizumab) with step therapy typically requiring eculizumab (Soliris) first. Submit PA through OptumRx (1-800-711-4555) or UnitedHealthcare provider portal. If denied, request peer-to-peer review within one business day, then file internal appeal within 180 days. Ohio residents can request external review through the Ohio Department of Insurance if internal appeals fail. First step today: Verify if your plan covers Ultomiris under medical or pharmacy benefits and gather diagnosis, prior treatment records, and lab results.

Table of Contents

Understanding UnitedHealthcare's Coverage Requirements

Ultomiris (ravulizumab) is a long-acting complement inhibitor used to treat paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD). With an annual cost often exceeding $450,000, UnitedHealthcare requires extensive documentation before approval.

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all indications OptumRx or provider portal UnitedHealthcare PA Requirements
Step Therapy Eculizumab (Soliris) typically required first Plan formulary OptumRx Guidelines
Benefit Type Medical benefit (provider-administered) Member services UnitedHealthcare Provider Portal
Appeals Deadline 180 days from denial EOB/denial letter Ohio Department of Insurance
External Review Available after internal appeals Ohio DOI External Review Process
Note: UnitedHealthcare manages pharmacy benefits through OptumRx, but Ultomiris is typically covered under the medical benefit since it requires provider administration.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Benefit Type

Who: Patient or clinic staff
Document needed: Insurance card, member ID
How: Call UnitedHealthcare member services or check provider portal
Timeline: Same day
Source: UnitedHealthcare Provider Portal

2. Gather Required Documentation

Who: Healthcare provider
Documents needed:

  • Confirmed diagnosis with ICD-10 codes
  • Laboratory results (LDH, hemoglobin, complement studies)
  • Prior treatment history and failures
  • Vaccination records (meningococcal required)
  • Clinical notes supporting medical necessity

Timeline: 1-3 business days

3. Submit Prior Authorization Request

Who: Healthcare provider or designated staff
How: OptumRx portal or call 1-800-711-4555
Timeline: Decision within 5-15 business days
Source: OptumRx PA Guidelines

4. Request Peer-to-Peer Review (if Initially Denied)

Who: Prescribing physician
When: Within one business day of denial
How: Contact UnitedHealthcare medical director
Timeline: Discussion within 24 hours
Source: UnitedHealthcare Peer Review Process

5. File Internal Appeal

Who: Patient or provider
When: Within 180 days of denial
How: Submit through member portal or mail to address on denial letter
Timeline: Decision within 30-60 days

6. Request External Review (Ohio)

Who: Patient
When: Within 180 days of final internal denial
How: Submit request to UnitedHealthcare; they forward to Ohio DOI
Timeline: Decision within 30 days (standard) or 72 hours (expedited)
Source: Ohio External Review

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document eculizumab trial and failure/intolerance Treatment records, adverse events, inadequate response data
Insufficient medical necessity Provide comprehensive clinical documentation Lab values, functional assessments, treatment goals
Missing vaccination records Submit proof of meningococcal vaccination Vaccination records or contraindication documentation
Incorrect benefit type Clarify medical vs. pharmacy benefit Provider administration requirements, site of care
Experimental/investigational Cite FDA approval and guidelines FDA labeling, clinical practice guidelines
Tip: Document specific reasons why eculizumab failed or is inappropriate. Common reasons include inadequate response (persistent hemolysis), dosing frequency challenges, or adverse reactions.

Medical Necessity Criteria by Condition

Paroxysmal Nocturnal Hemoglobinuria (PNH)

Required Documentation:

  • Laboratory evidence of complement protein deficiencies (CD55, CD59) in ≥2 cell lines
  • LDH ≥1.5 × upper limit of normal
  • Symptomatic disease with hemoglobin <10 g/dL or complications
  • Prior eculizumab use or treatment-naïve status acceptable

Source: Medical Necessity Criteria

Generalized Myasthenia Gravis (gMG)

Required Documentation:

  • Positive anti-acetylcholine receptor (AChR) antibodies
  • MGFA Clinical Classification II-IV disease
  • MG-ADL score ≥6
  • Failed ≥1 year of dual immunosuppressive therapy
  • Prescribed by neurologist

Atypical Hemolytic Uremic Syndrome (aHUS)

Required Documentation:

  • Confirmed aHUS diagnosis (excluding STEC-HUS)
  • Meningococcal vaccination ≥2 weeks prior
  • No recent rituximab, mitoxantrone, or IVIG

Neuromyelitis Optica Spectrum Disorder (NMOSD)

Required Documentation:

  • Anti-aquaporin-4 (AQP4) antibody positive
  • ≥1 relapse in past 12 months
  • EDSS ≤7.0
  • Alternative diagnoses excluded

Appeals Process in Ohio

Ohio provides strong consumer protections for insurance appeals, including independent external review through the Ohio Department of Insurance.

Internal Appeals (Required First Step)

  • Deadline: 180 days from denial notice
  • Process: Submit through UnitedHealthcare member portal or mail
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Reviewer: UnitedHealthcare medical director with appropriate specialty

External Review (After Internal Appeals)

  • Eligibility: Medical necessity denials after completing internal appeals
  • Deadline: 180 days from final internal denial
  • Process: Submit request to UnitedHealthcare; they forward to Ohio DOI
  • Cost: Free to patient
  • Reviewer: Independent Review Organization (IRO) with relevant medical expertise
  • Timeline: 30 days standard, 72 hours expedited
  • Decision: Binding on UnitedHealthcare

Contact for Help: Ohio Department of Insurance Consumer Hotline: 1-800-686-1526

Source: Ohio Appeals Process

Scripts and Templates

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about prior authorization for Ultomiris (ravulizumab) for [condition]. My member ID is [number]. Can you tell me:

  1. Is this covered under medical or pharmacy benefits?
  2. What documentation is required?
  3. Is step therapy with eculizumab required?
  4. What's the current processing timeline?"

Peer-to-Peer Request Script for Providers

"I'm requesting a peer-to-peer review for [patient name], member ID [number], regarding the denial of Ultomiris for [condition]. The denial was issued on [date]. I have additional clinical information that supports medical necessity. When can we schedule a discussion with your medical director?"

Cost Assistance Options

Manufacturer Support

  • Alexion Access Navigator: Patient assistance program offering copay support and free drug programs
  • Eligibility: Income-based for uninsured/underinsured patients
  • Contact: Visit alexionaccessnavigator.com or call program directly

Foundation Grants

  • Patient Advocate Foundation: Copay relief fund for eligible patients
  • National Organization for Rare Disorders (NORD): Assistance programs for rare disease medications
  • Eligibility: Varies by program; typically income-based

State Programs

Ohio residents may qualify for additional assistance through state pharmaceutical programs or Medicaid coverage for eligible individuals.

From our advocates: We've seen cases where patients initially denied for Ultomiris received approval after submitting comprehensive documentation showing eculizumab intolerance due to infusion reactions and subsequent disease progression. The key was detailed adverse event documentation and objective measures like rising LDH levels. While outcomes vary by case, thorough clinical documentation significantly improves approval chances.

FAQ: UnitedHealthcare Ultomiris Coverage

How long does UnitedHealthcare prior authorization take for Ultomiris?

Standard review takes 5-15 business days. Expedited review (for urgent medical needs) typically completes within 72 hours.

What if Ultomiris is non-formulary on my plan?

Non-formulary medications can still receive coverage through the medical exception process. Submit comprehensive medical necessity documentation and consider requesting a formulary exception.

Can I request expedited appeal if my condition is worsening?

Yes. Ohio allows expedited appeals when delays could seriously jeopardize health. Contact UnitedHealthcare immediately and request expedited review, providing documentation of urgent medical need.

Does step therapy apply if I failed eculizumab outside Ohio?

Yes. UnitedHealthcare's step therapy requirements apply regardless of where prior treatment occurred. Document the previous trial with medical records and failure/intolerance details.

What happens if external review denies my appeal?

External review decisions are binding on UnitedHealthcare, but you retain rights to file regulatory complaints or pursue legal remedies. Consider consulting with a healthcare attorney or patient advocate.

How do I know if Ultomiris is covered under medical or pharmacy benefits?

Contact UnitedHealthcare member services or check your plan documents. Since Ultomiris requires provider administration, it's typically covered under medical benefits rather than through OptumRx pharmacy benefits.

Counterforce Health specializes in helping patients navigate complex insurance denials for specialty medications like Ultomiris. Our platform analyzes denial letters, identifies specific appeal strategies, and generates targeted rebuttals using evidence-based approaches tailored to each payer's requirements. By turning insurance denials into structured, evidence-backed appeals, we help patients and providers achieve better approval outcomes for critical treatments.

When to Escalate

Contact the Ohio Department of Insurance if:

  • UnitedHealthcare fails to respond within required timeframes
  • You believe the denial violates Ohio insurance law
  • The external review process is improperly denied

Ohio Department of Insurance
Consumer Services Division
Phone: 1-800-686-1526
Website: insurance.ohio.gov

Checklist: What to Gather Before You Start

  • Insurance card and member ID
  • Complete diagnosis with ICD-10 codes
  • Laboratory results (LDH, hemoglobin, complement studies)
  • Prior treatment records and outcomes
  • Meningococcal vaccination records
  • Current clinical notes and treatment plan
  • Previous denial letters or EOBs
  • Provider contact information and NPI numbers

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions vary by plan and individual circumstances. Always consult with your healthcare provider and insurance company for plan-specific requirements. For personalized assistance with insurance appeals and prior authorization challenges, consider working with Counterforce Health to develop targeted, evidence-based appeal strategies.

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