By Counterforce Health Team in Voydeya (danicopan) —

How to Get Voydeya (danicopan) Covered by UnitedHealthcare in Michigan: Prior Authorization Forms, Appeals, and Approval Timeline

Quick Answer: Your Path to Voydeya Coverage in Michigan

Getting Voydeya (danicopan) covered by UnitedHealthcare in Michigan requires prior authorization with specific documentation: confirmed PNH diagnosis by flow cytometry, evidence of extravascular hemolysis despite C5 inhibitor therapy, completed REMS program enrollment, and current vaccination records (MenACWY and MenB). Submit through the OptumRx provider portal with supporting clinical notes. Standard decisions take 7-14 business days; expedited requests (with physician attestation) get decided within 72 hours. If denied, you have strong appeal rights in Michigan, including external review through DIFS within 127 days.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timeline Expectations
  7. Handling Requests for Additional Information
  8. If Your Request Is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps Michigan patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Voydeya (danicopan), an oral Factor D inhibitor used as add-on therapy for paroxysmal nocturnal hemoglobinuria (PNH).

Voydeya isn't used alone—it's prescribed alongside C5 inhibitors like eculizumab (Soliris) or ravulizumab (Ultomiris) to address extravascular hemolysis that persists despite standard treatment. With list prices ranging from $50,000-$100,000 annually (plus your existing C5 inhibitor costs), securing insurance coverage is crucial.

You'll learn exactly what documentation UnitedHealthcare requires, how to submit your request efficiently, and what to do if you're initially denied. Michigan residents have particularly strong appeal rights through the state's Department of Insurance and Financial Services (DIFS).

Before You Start: Plan Verification

Confirm Your Plan Type

UnitedHealthcare operates several plan types in Michigan, each with different rules:

  • Commercial plans (employer-sponsored): Follow Michigan state regulations
  • Medicare Advantage: Federal rules with some state oversight
  • Individual marketplace plans: Michigan DIFS external review rights

Check your insurance card or call the member services number to confirm your specific plan type.

Verify Formulary Status

Voydeya requires prior authorization across most UnitedHealthcare plans. Check your plan's formulary through the UnitedHealthcare member portal or by calling the pharmacy benefit number on your card. The drug is typically placed on specialty tiers requiring significant cost-sharing even after approval.

Understand Step Therapy Requirements

UnitedHealthcare has implemented expanded step therapy requirements for high-cost specialty medications. For PNH treatments, this typically means:

  • Documented trial of preferred C5 inhibitor therapy
  • Evidence of inadequate response (persistent extravascular hemolysis)
  • Clinical justification for combination therapy

Existing users within the past 365 days may be exempt from step therapy requirements.

Gather Required Documentation

Essential Clinical Documentation

PNH Diagnosis Confirmation:

  • Flow cytometry results showing PNH clone size (CD55/CD59 deficiency)
  • ICD-10 code: D59.5 (Paroxysmal nocturnal hemoglobinuria)
  • Diagnostic labs confirming hemolysis (LDH, indirect bilirubin, haptoglobin)

Evidence of Extravascular Hemolysis:

  • Current hemoglobin levels and transfusion requirements
  • Reticulocyte count elevation
  • Documentation of symptoms despite C5 inhibitor therapy
  • Specialist attestation of inadequate response to current treatment

REMS Program Requirements:

  • Prescriber enrollment in Voydeya REMS program
  • Patient counseling documentation
  • Vaccination records: MenACWY and MenB (completed ≥2 weeks before treatment)
  • If urgent therapy needed: antibiotic prophylaxis plan

Prior Authorization Forms

Use the current OptumRx Prior Authorization Request Form (verify with the source linked). Complete all sections including:

  • Patient demographics and insurance information
  • Prescriber details with NPI number
  • Medication specifics (Voydeya 150mg TID, may increase to 200mg TID)
  • Clinical rationale and supporting documentation
  • Prescriber signature and date

Submit Your Prior Authorization Request

Submit through the UnitedHealthcare provider portal or compatible ePA platforms like CoverMyMeds. Electronic submission offers:

  • Faster processing (often automated for qualifying requests)
  • Real-time status tracking
  • Reduced risk of missing documentation

Fax Submission Alternative

If electronic submission isn't available, fax to 1-844-403-1027 (verify current number with OptumRx). Include:

  • Completed PA form
  • All supporting clinical documentation
  • Cover sheet with patient information and urgency level

Specialty Pharmacy Coordination

Voydeya is dispensed through specialty pharmacies. Coordinate with:

  • Your preferred specialty pharmacy
  • UnitedHealthcare's contracted specialty network
  • Manufacturer's support programs (Alexion's Voydeya Complete)
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Voydeya. Their platform can help identify specific denial reasons and draft point-by-point rebuttals aligned to your plan's policies.

Follow-Up and Tracking

When to Call

Contact UnitedHealthcare if you haven't received a decision within:

  • Standard requests: 10 business days
  • Expedited requests: 3 business days

Sample Call Script

"I'm calling to check the status of a prior authorization request for Voydeya (danicopan) submitted on [date] for patient [name], member ID [number]. The reference number is [if available]. Can you provide the current status and expected decision timeline?"

Document all interactions with reference numbers, representative names, and next steps.

Typical Timeline Expectations

Standard Processing

  • UnitedHealthcare decision: 7-14 business days
  • Expedited review: 72 hours (requires physician attestation of urgency)
  • Additional information requests: May extend timeline by 5-10 days

Michigan-Specific Timelines

Commercial plans in Michigan must follow state regulations for timely decisions. If UnitedHealthcare exceeds reasonable timeframes, you can file a complaint with Michigan DIFS.

Handling Requests for Additional Information

Common requests include:

  • More detailed clinical notes: Provide comprehensive progress notes documenting PNH symptoms and treatment response
  • Laboratory trending: Submit serial hemoglobin, LDH, and reticulocyte counts
  • Specialist consultation: Include hematologist's assessment and treatment recommendations
  • Vaccination verification: Provide dated immunization records or contraindication documentation

Respond promptly to avoid delays. Most insurers allow 14 days for additional information submission.

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason Solution
Missing REMS documentation Submit prescriber enrollment proof and patient counseling records
Inadequate evidence of EVH Provide detailed labs showing persistent hemolysis despite C5 therapy
Step therapy not met Document previous C5 inhibitor trials and clinical response
Non-specialist prescriber Obtain hematologist consultation and co-signature

Internal Appeals Process

File an internal appeal within 180 days of denial through:

Michigan External Review Rights

If your internal appeal is denied, you have strong rights under Michigan law:

  • Timeline: 127 days from final internal denial to request external review
  • Process: Submit request to Michigan DIFS
  • Expedited review: 72 hours for urgent cases with physician support
  • Binding decision: DIFS external review decisions are final and binding on UnitedHealthcare

Michigan's external review process has proven effective, with independent medical experts often overturning insurer denials based on clinical evidence.

Renewal and Re-Authorization

Planning Ahead

Most approvals are granted for 12 months. Begin renewal process 30-45 days before expiration:

  • Update clinical documentation showing continued medical necessity
  • Include current lab values and symptom assessment
  • Document any dose adjustments or treatment modifications

Required Updates

Submit fresh documentation including:

  • Recent hemoglobin trends and transfusion needs
  • Updated vaccination status
  • Continued REMS compliance
  • Specialist assessment of treatment response

Quick Reference Checklist

Before Submitting:

  • Confirm PNH diagnosis with flow cytometry results
  • Document extravascular hemolysis despite C5 inhibitor
  • Verify REMS program enrollment (prescriber and patient)
  • Obtain vaccination records (MenACWY and MenB)
  • Complete current OptumRx PA form
  • Gather 12 months of clinical notes and labs

Submission:

  • Submit via provider portal or fax to 1-844-403-1027
  • Include all supporting documentation
  • Request expedited review if medically urgent
  • Coordinate with specialty pharmacy

Follow-Up:

  • Track submission with reference number
  • Follow up if no decision within expected timeframe
  • Respond promptly to requests for additional information
  • Prepare for potential appeal if denied

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all plans UHC Specialty Drug List
REMS Enrollment Mandatory for prescriber and patient Voydeya REMS Program
Vaccinations MenACWY and MenB ≥2 weeks before treatment CDC immunization records
Diagnosis Code ICD-10: D59.5 (PNH) Medical records
Appeal Deadline 180 days internal, 127 days external (Michigan) Michigan DIFS
From Our Advocates: We've seen cases where patients initially denied for Voydeya successfully obtained coverage after providing detailed documentation of persistent fatigue and transfusion requirements despite optimized C5 inhibitor therapy. The key was working closely with the hematologist to clearly document extravascular hemolysis markers and submitting comprehensive vaccination records upfront. This approach helped avoid common denial reasons and streamlined the approval process.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Michigan? Standard requests: 7-14 business days. Expedited requests with physician attestation: 72 hours. Michigan state law provides additional consumer protections for timely decisions.

What if Voydeya isn't on my formulary? Non-formulary medications can still be covered through the prior authorization process with strong clinical justification. Focus on documenting medical necessity and lack of formulary alternatives.

Can I request an expedited appeal? Yes, if your health would be jeopardized by delay. Your physician must provide supporting documentation of urgency. Michigan offers 72-hour expedited external review for urgent cases.

Does step therapy apply if I'm already on a C5 inhibitor? Existing users within 365 days are typically exempt from step therapy. New users may need to demonstrate inadequate response to preferred C5 inhibitor monotherapy.

What financial assistance is available? Alexion offers patient support through Voydeya Complete, including copay assistance for eligible patients. Foundation grants and state programs may also provide support.

When should I contact Michigan DIFS? Contact DIFS if UnitedHealthcare denies your internal appeal or fails to meet response timelines. DIFS provides free external review services for Michigan residents.

This guide provides general information about insurance coverage and should not be considered medical advice. Coverage decisions depend on individual circumstances and plan benefits. For personalized assistance with complex prior authorizations and appeals, Counterforce Health helps patients and providers navigate insurance denials with targeted, evidence-backed strategies.

Disclaimer: 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. Michigan residents should contact Michigan Department of Insurance and Financial Services for official guidance on insurance appeals and external review processes.

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