By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (ravulizumab) Covered by UnitedHealthcare in Pennsylvania: Complete Guide to Prior Authorization, Appeals & Forms

Quick Answer: Getting Ultomiris Covered by UnitedHealthcare in Pennsylvania

To get Ultomiris (ravulizumab) covered by UnitedHealthcare in Pennsylvania, you'll need prior authorization through OptumRx. The fastest path: 1) Have your doctor submit a PA request via the UnitedHealthcare provider portal with complete clinical documentation, 2) Include proof of eculizumab (Soliris) failure or contraindication to meet step therapy requirements, and 3) Ensure meningococcal vaccination records are attached. If denied, use Pennsylvania's new external review program—about 50% of appeals are overturned. Start by calling UnitedHealthcare member services at 1-800-624-8822 to verify your specific plan requirements.

Table of Contents

Verify Your Plan & Find the Right Forms

Before starting your Ultomiris prior authorization, confirm your specific UnitedHealthcare plan details. OptumRx manages pharmacy benefits for most UnitedHealthcare plans as of 2024, but requirements can vary by plan type.

What to verify:

  • Whether your plan requires prior authorization for Ultomiris
  • Your formulary tier placement
  • Step therapy requirements (typically eculizumab first)
  • Specialty pharmacy network restrictions
Tip: Log into your UnitedHealthcare member portal or call member services at 1-800-624-8822 to get your specific plan's Ultomiris coverage policy.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all plans UnitedHealthcare PA requirements
Step Therapy Eculizumab (Soliris) or biosimilar first Complement inhibitor policy
Specialty Pharmacy Network-only dispensing Specialty pharmacy list
Meningococcal Vaccination Required pre-treatment FDA REMS program
Appeals Deadline 180 days from denial Member handbook

Required Forms & Documentation

Your healthcare provider must submit a comprehensive prior authorization request through OptumRx. Here's what's needed:

Clinical Documentation Checklist

  • Confirmed diagnosis with ICD-10 codes (PNH, aHUS, generalized myasthenia gravis, or NMOSD)
  • Laboratory confirmation of diagnosis-specific markers
  • Step therapy documentation: Proof of eculizumab failure, intolerance, or contraindication
  • Meningococcal vaccination records (at least 2 weeks prior to treatment)
  • Treatment history including prior immunosuppressive therapies
  • Clinical rationale for Ultomiris over alternatives
Clinician Corner: The medical necessity letter should specifically address why the extended dosing interval of Ultomiris (every 8 weeks) is clinically appropriate compared to eculizumab's every 2-week schedule. Include patient-specific factors like adherence challenges or quality of life improvements.

Required REMS Documentation

Ultomiris carries the same REMS requirements as Soliris due to meningococcal infection risk. Your submission must include:

  • Attestation of meningococcal vaccination completion
  • Documentation that patient has no active meningococcal infection
  • Patient counseling acknowledgment forms

Submission Portals & Upload Process

UnitedHealthcare offers several submission methods, with the provider portal being the most efficient.

UnitedHealthcare Provider Portal

  1. Access: Visit UHCProvider.com and log into the provider portal
  2. Navigate: Select "Specialty Pharmacy Transactions" tile
  3. Upload: Attach all clinical documentation directly with the PA request
  4. Track: Monitor status through the portal dashboard

PreCheck MyScript Automation

For eligible requests, OptumRx's PreCheck system can auto-approve PAs in as little as 29 seconds by pulling data directly from your EMR. This works best when all clinical criteria are clearly documented in structured fields.

Standard processing times:

  • Urgent requests: 24 hours
  • Non-urgent requests: 72 hours
  • PreCheck eligible: Median 29 seconds

Fax & Mail Options

If portal submission isn't available, you can use traditional methods:

OptumRx Prior Authorization Fax: Contact OptumRx at 1-800-711-4555 for current fax numbers (they vary by plan type)

Mail Address: Confirm current mailing address through the provider portal or by calling OptumRx, as addresses may change.

Note: Always include a detailed cover sheet with patient information, drug name, and urgency level when faxing documentation.

Specialty Pharmacy Network

Ultomiris must be dispensed through UnitedHealthcare's contracted specialty pharmacy network. You cannot use retail pharmacies for this medication.

Approved Pennsylvania Specialty Pharmacies

  • Accredo Health Group: 877-222-7336
  • AllianceRx Walgreens: 888-282-5166
  • CVS Specialty (Caremark): 800-237-2767
  • Optum Specialty Pharmacy: 855-427-4682
  • Option Care Health: 833-730-4673
  • PANTHERx Rare Pharmacy: 855-726-8479 ext. 1115

Pennsylvania Dispensing Location

Zeal Specialty Pharmacy
100 Business Center Dr, Suite 300
Pittsburgh, PA 15205

Enrollment Process

  1. Contact your chosen specialty pharmacy from the approved list
  2. Complete their enrollment forms (available online or by phone)
  3. Provide insurance information and clinical documentation
  4. Coordinate with your prescriber for prescription transfer if switching pharmacies

Support Lines & Contact Numbers

For Patients

  • UnitedHealthcare Member Services: 1-800-624-8822
  • OptumRx Member Services: Number on your insurance card
  • Pennsylvania Insurance Department Consumer Helpline: 1-877-881-6388

For Providers

  • OptumRx Prior Authorization: 1-800-711-4555
  • UnitedHealthcare Provider Services: 888-397-8129
  • Peer-to-peer review requests: Available through provider portal

What to ask when calling:

  • Current PA status and any missing documentation
  • Step therapy exception process
  • Expedited review criteria
  • Appeal submission requirements

Pennsylvania Appeals & External Review

Pennsylvania launched its own external review program in January 2024, giving patients a powerful new tool to overturn insurance denials.

Internal Appeals Process

  1. Submit internal appeal within 180 days of denial
  2. Include all supporting documentation and clinical rationale
  3. Wait for UnitedHealthcare's internal decision (typically 30-60 days)
  4. Receive Final Adverse Benefit Determination letter

Pennsylvania External Review Program

If your internal appeal is denied, you can request an independent external review through the Pennsylvania Insurance Department.

Key statistics: About 50% of external appeals in Pennsylvania's first year were decided in favor of patients, resulting in coverage for previously denied treatments.

Process:

  1. Deadline: 4 months from final internal denial
  2. Submit: Online at pa.gov or by mail/fax
  3. Timeline: 45 days for standard review, 72 hours for urgent cases
  4. Outcome: If approved, UnitedHealthcare must provide coverage immediately
Pennsylvania residents benefit from one of the strongest external review programs in the country. Don't hesitate to use this option if your internal appeal is denied.

Appeals Contact Information

UnitedHealthcare Appeals Address:
UnitedHealthcare
Attn: Provider Contract Appeals
P.O. Box 31376
Salt Lake City, UT 84131-0376

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not met Document eculizumab failure/intolerance Treatment records, adverse event notes
Insufficient medical necessity Strengthen clinical rationale Lab values, symptom progression, quality of life impact
Missing REMS requirements Complete vaccination documentation Vaccination records, patient counseling forms
Non-formulary status Request formulary exception Comparative effectiveness data, cost analysis
Quantity/frequency limits Justify dosing based on FDA labeling Weight-based calculations, clinical guidelines

Step Therapy Exception Strategies

Since UnitedHealthcare typically requires eculizumab trial first, document:

  • Clinical failures: Breakthrough hemolysis, continued transfusion needs
  • Intolerance: Infusion reactions, injection site issues
  • Contraindications: Drug interactions, comorbidities
  • Adherence challenges: Transportation barriers for frequent dosing

Cost Assistance Programs

Ultomiris costs approximately $474,000-$569,000 annually, making financial assistance crucial for many patients.

Manufacturer Support

  • Alexion Access Navigator: alexionaccessnavigator.com
  • Patient assistance programs: Income-based eligibility
  • Copay support: For commercially insured patients

Foundation Grants

  • Patient Advocate Foundation
  • HealthWell Foundation
  • National Organization for Rare Disorders (NORD)

State Programs

Pennsylvania residents may qualify for additional state-based assistance programs. Contact the Pennsylvania Insurance Department for current options.

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by crafting targeted, evidence-backed responses that address each payer's specific requirements. Our platform ingests denial letters, plan policies, and clinical notes to identify the exact denial basis and draft point-by-point rebuttals aligned to the plan's own rules.

FAQ

How long does UnitedHealthcare PA take for Ultomiris in Pennsylvania?
Standard requests take up to 72 hours once complete documentation is received. Urgent requests are processed within 24 hours. PreCheck-eligible submissions can be approved in under a minute.

What if Ultomiris is non-formulary on my plan?
Request a formulary exception by demonstrating medical necessity and providing evidence that formulary alternatives are inappropriate or ineffective for your condition.

Can I request an expedited appeal in Pennsylvania?
Yes, if your condition poses an imminent health threat. Expedited external reviews through Pennsylvania's program are decided within 72 hours.

Does step therapy apply if I failed eculizumab outside Pennsylvania?
Yes, step therapy requirements are based on your medical history regardless of where treatment occurred. Ensure your out-of-state treatment records are included in your PA submission.

What happens if my specialty pharmacy isn't in Pennsylvania?
UnitedHealthcare's contracted specialty pharmacies can ship Ultomiris to Pennsylvania addresses. You're not limited to in-state pharmacy locations.

How do I transfer from another specialty pharmacy?
Contact both your current and new specialty pharmacies to initiate the transfer. Your prescriber may need to send a new prescription to the receiving pharmacy.

What if I'm switching from Soliris to Ultomiris?
Document your current Soliris response and provide clinical rationale for switching (e.g., improved convenience, better adherence with less frequent dosing).

Can I appeal to Pennsylvania if I have a Medicare Advantage plan?
Yes, Pennsylvania's external review program covers all health insurance plans, including Medicare Advantage plans offered by UnitedHealthcare.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently—always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions.

Sources & Further Reading

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