By Counterforce Health Team in Uplizna (inebilizumab) —

How to Get Uplizna (Inebilizumab) Covered by UnitedHealthcare in North Carolina: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Uplizna Covered by UnitedHealthcare in North Carolina

UnitedHealthcare requires prior authorization for Uplizna (inebilizumab) for both AQP4-positive NMOSD and IgG4-related disease. Fastest path: Have your neurologist or rheumatologist submit PA via UHC Provider Portal with AQP4-IgG test results (for NMOSD), prior therapy failures, and medical necessity letter. If denied, appeal internally within 180 days, then request external review through Smart NC within 120 days. Start today: Contact your specialist to begin PA submission and enroll in Amgen's copay assistance program if commercially insured.

Table of Contents

What Drives Uplizna Costs

Uplizna carries a list price of approximately $140,248.50 per dose, with year one costs around $420,000 (three doses) and subsequent years at $280,000 (two doses annually). These costs are driven by several factors:

Benefit Design Basics: As an infused specialty medication, Uplizna is typically covered under your medical benefit rather than prescription drug benefit. This means it's subject to your medical deductible, coinsurance, and out-of-pocket maximum rather than prescription copays.

Tiering Influences: UnitedHealthcare classifies Uplizna as a specialty medication requiring use of their preferred specialty pharmacy network, typically OptumRx Specialty Pharmacy. The medication is generally placed on Tier 3 (higher-cost brand) with prior authorization, step therapy requirements, and quantity limits.

For Medicare beneficiaries, the 2025 out-of-pocket cap of $2,000 applies to Part D drugs, but Uplizna falls under Medicare Part B (medical benefit) and isn't subject to this cap.

Understanding Your UnitedHealthcare Benefits

Before pursuing coverage, gather this essential information:

What to Ask Your Insurer

  • Is Uplizna covered under medical or pharmacy benefits?
  • What's my specialty medication deductible and coinsurance?
  • Which specialty pharmacies are in-network?
  • Are there quantity limits or step therapy requirements?

Information to Record

  • Member ID and group number
  • Plan type (commercial, Medicare Advantage, Medicaid)
  • Deductible amounts (medical vs. pharmacy)
  • Out-of-pocket maximum
  • Specialist copay amounts
Tip: Call the member services number on your insurance card and ask specifically about "J-code J1823" coverage, as this is how Uplizna is billed.

Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Uplizna across all plan types. Requirements vary by indication:

Coverage at a Glance

Requirement NMOSD IgG4-Related Disease Source
Diagnosis AQP4-IgG positive (ICD-10 G36.0) ACR/EULAR criteria (ICD-10 D89.84) UHC Policy
Specialist Neurologist Rheumatologist UHC Policy
Prior Therapy Rituximab failure/contraindication Glucocorticoid inadequacy UHC Policy
Safety Screen HBV testing HBV testing UHC Policy

Step-by-Step: Fastest Path to Approval

  1. Confirm Diagnosis (Patient/Clinic): Ensure AQP4-IgG testing is documented for NMOSD or ACR/EULAR criteria met for IgG4-RD
  2. Gather Prior Therapy Records (Clinic): Document previous treatments, doses, durations, and reasons for discontinuation
  3. Complete HBV Screening (Patient): Required safety screening before approval
  4. Submit PA Request (Clinic): Use UHC Provider Portal or call 877-842-3210; include all documentation initially
  5. Track Timeline (Patient/Clinic): Standard review takes 5-7 business days; expedited available for urgent cases
  6. Peer-to-Peer if Needed (Clinic): Request physician-to-physician review if initially denied
  7. Appeal if Denied (Patient/Clinic): File internal appeal within 180 days with additional evidence

Assistance Options and Cost Savings

Manufacturer Copay Programs

Amgen By Your Side offers eligible commercially insured patients a $0 copay for both the drug and infusion costs. Key requirements:

  • Commercial insurance (not Medicare/Medicaid)
  • U.S. or Puerto Rico resident, 18+ years old
  • Healthcare provider enrollment required

How to Enroll: Your doctor downloads the Patient Enrollment Form from upliznahcp.com, completes it, and submits via fax (833-329-8477) or email ([email protected]).

Foundation Grants

For Medicare/Medicaid patients ineligible for manufacturer assistance, explore:

  • Patient Access Network Foundation
  • Good Days Foundation
  • HealthWell Foundation

Contact Amgen SupportPlus for guidance on foundation applications.

Case Management

Counterforce Health specializes in turning insurance denials into targeted appeals for complex medications like Uplizna. Their platform analyzes denial letters and plan policies to create evidence-backed rebuttals that align with UnitedHealthcare's specific requirements.

Appeals Process in North Carolina

North Carolina provides strong consumer protections for insurance denials through its Smart NC program.

Internal Appeals (UnitedHealthcare)

  • Timeline: 180 days from denial date
  • Levels: Two internal appeal levels
  • Expedited: Available for urgent cases (≤72 hours)
  • Submission: Via provider portal, fax, or mail

External Review (Smart NC)

After exhausting internal appeals, North Carolina residents can request external review through Smart NC:

Process Overview:

  • Eligibility: State-regulated plans (not self-funded employer plans unless opted in)
  • Timeline: 120 days after final internal denial
  • Contact: 1-855-408-1212 or online form
  • Decision: 45 days standard, 72 hours expedited
  • Binding: If approved, insurer must provide coverage within 3 business days
Note: Smart NC staff provide free advocacy and can help gather supporting evidence for your external review.

Specialty Pharmacy and Administration

Uplizna requires specialty pharmacy handling due to its complex storage and administration requirements.

OptumRx Requirements

UnitedHealthcare typically requires use of OptumRx Specialty Pharmacy for delivery to your infusion site. The medication cannot be dispensed through regular retail pharmacies.

Coordination Steps:

  1. Once PA is approved, contact OptumRx to enroll
  2. Specialty pharmacist coordinates with your infusion center
  3. Medication is shipped directly to administration site
  4. Infusion nurse administers per protocol (300mg IV over ~90 minutes)

Administration Sites

Uplizna can be administered at:

  • Physician offices with infusion capabilities
  • Hospital outpatient infusion centers
  • Certified home infusion services

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documentation Needed
Not AQP4-positive Submit lab results showing AQP4-IgG antibodies Original lab report with positive result
Inadequate prior therapy Document rituximab trial/failure Treatment records, adverse event notes
Missing specialist involvement Neurologist/rheumatologist consultation Recent specialist evaluation (within 6 months)
Incomplete HBV screening Complete hepatitis B testing HBsAg, anti-HBc, anti-HBs results
Site of care issues Verify in-network infusion center Provider network verification

Scripts and Templates

Patient Phone Script for UnitedHealthcare

"Hi, I'm calling about prior authorization status for Uplizna, J-code J1823, for my [NMOSD/IgG4-related disease]. My member ID is [number]. Can you tell me the current status and what additional information might be needed?"

Clinic Staff Peer-to-Peer Request

"I'm requesting a peer-to-peer review for [patient name], member ID [number], regarding denial of Uplizna for AQP4-positive NMOSD. The patient has failed rituximab due to [specific reason] and meets all clinical criteria per your policy. When can we schedule the physician review?"

Medical Necessity Letter Template

Key elements to include:

  • Confirmed AQP4-IgG positive status with lab date
  • Prior treatment history (medications, doses, duration, outcomes)
  • Current relapse frequency and disability status
  • Contraindications to alternative therapies
  • References to FDA labeling and clinical guidelines

FAQ

How long does UnitedHealthcare PA take in North Carolina? Standard prior authorization takes 5-7 business days. Expedited review is available for urgent cases and typically completed within 72 hours.

What if Uplizna is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. Include clinical evidence supporting Uplizna's superiority for your specific case.

Can I request expedited appeal if denied? Yes, if your condition is urgent or if delay would seriously jeopardize your health. Both internal appeals and external review through Smart NC offer expedited options.

Does step therapy apply if I failed rituximab in another state? Yes, documented treatment failures from other states count toward step therapy requirements if properly documented in your medical records.

What happens if Smart NC overturns the denial? The decision is binding on UnitedHealthcare. They must provide coverage within 3 business days of the external review decision.

Can I use manufacturer copay assistance with Medicare? No, federal law prohibits manufacturer copay assistance for government insurance beneficiaries. Explore patient foundation grants instead.

How do I find an in-network infusion center? Use UnitedHealthcare's provider directory online or call member services. Ensure the facility can handle specialty pharmacy deliveries from OptumRx.

What if I need Uplizna for the new IgG4-related disease indication? Some plans may not have updated their policies yet. Submit PA with FDA approval documentation and request coverage under the new indication approved in 2025.

Counterforce Health helps patients and clinicians navigate complex prior authorization processes for specialty medications like Uplizna. Their evidence-based platform turns insurance denials into targeted appeals that align with specific payer requirements, reducing delays in accessing critical treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and circumstances. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. For additional help with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212.

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