By Counterforce Health Team in Xospata (gilteritinib) —

How to Get Xospata (gilteritinib) Covered by UnitedHealthcare in Michigan: Forms, Appeals & Step-by-Step Guide

Answer Box: Getting Xospata Approved by UnitedHealthcare in Michigan

Xospata (gilteritinib) requires prior authorization through OptumRx for UnitedHealthcare members in Michigan. Your oncologist must submit clinical documentation proving FLT3-mutated relapsed/refractory AML diagnosis, prior therapy history, and medical necessity via the UnitedHealthcare Provider Portal or by calling 1-800-711-4555. If denied, you have 180 days for internal appeals and 127 days for Michigan DIFS external review (877-999-6442). First step today: Confirm your plan covers specialty medications and ask your doctor to initiate the prior authorization request with complete FLT3 mutation testing results.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Access
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Setup
  6. Support Lines and Who to Call
  7. Michigan Appeals and External Review
  8. Step-by-Step: Fastest Path to Approval
  9. Common Denial Reasons and Solutions
  10. Costs and Patient Assistance
  11. FAQ

Verify Your Plan and Find the Right Forms

Before starting the Xospata approval process, confirm your UnitedHealthcare plan details and coverage requirements.

What You Need to Check:

  • Your specific UnitedHealthcare plan type (commercial, Medicare Advantage, Medicaid)
  • Whether your plan uses OptumRx for specialty pharmacy benefits
  • Current formulary status for Xospata (typically requires PA and specialty pharmacy)
Tip: Call the member services number on your insurance card to verify specialty medication coverage and confirm you're enrolled with OptumRx for specialty drugs.

Key Policy Updates for 2025: UnitedHealthcare implemented new step therapy requirements for Medicare Advantage Part B plans starting January 1, 2025. If you're a new Xospata user, you may need to try preferred first-line AML therapies first, unless you have documented contraindications or treatment failures.

Prior Authorization Forms and Requirements

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans UnitedHealthcare Provider Portal OptumRx PA Process
Formulary Status PA + Specialty Pharmacy (SP) 2025 Michigan PDL Michigan Formulary
Step Therapy New users (Medicare Advantage) Medicare Part B Step Therapy Policy Step Therapy Requirements
Submission Method Provider Portal or Phone UHC Provider Resources Portal Access

Required Clinical Documentation

Your oncologist must provide:

  • Diagnosis confirmation: Relapsed/refractory AML with documented FLT3 mutation (ITD or TKD)
  • FLT3 testing results: FDA-approved test confirming mutation status
  • Prior therapy history: Details of previous treatments, dates, outcomes, and reasons for discontinuation
  • Medical necessity justification: Why Xospata is appropriate for your specific case
  • Prescriber credentials: Confirmation that prescriber is a qualified hematologist/oncologist

Submission Portals and Online Access

UnitedHealthcare Provider Portal

Primary submission method: UnitedHealthcare Provider Portal

  • Requires One Healthcare ID for provider login
  • Navigate to "Prior Authorization and Notification" section
  • Upload supporting documentation directly through the portal
  • Track request status and receive notifications

OptumRx Direct Access

For pharmacy-specific inquiries:

  • OptumRx portal: Available for authorized providers with HealthSafe ID
  • Phone submission: 1-800-711-4555 (Individual & Family plans)
  • Commercial plans: 1-800-711-4555
  • Medicaid plans: 888-397-8129
Note: Electronic submission through the provider portal typically results in faster processing times than phone or fax submissions.

Fax Numbers and Mailing Addresses

OptumRx Specialty Pharmacy Michigan

Prior Authorization Appeals Fax: 800-550-6272

Michigan Address: OptumRx Specialty Pharmacy
4100 S Saginaw St Ste D
Flint, MI 48507-2683

General Phone: 855-427-4682 (24/7 support)

New Prescription Fax (Physicians): 877-342-4596

Cover Sheet Tips

When faxing appeals or documentation:

  • Include patient's full name and UnitedHealthcare member ID
  • Reference the original prior authorization request number
  • Mark urgent requests as "EXPEDITED" if applicable
  • Include provider NPI and contact information
  • Request fax confirmation receipt

Specialty Pharmacy Setup

Xospata must be dispensed through OptumRx Specialty Pharmacy for UnitedHealthcare members.

Onboarding Steps:

  1. Provider submits prescription to OptumRx Specialty after PA approval
  2. Patient enrollment - OptumRx contacts patient to set up account
  3. Insurance verification - Pharmacy confirms coverage and copay
  4. Delivery coordination - Schedule first shipment (typically 30-day supply)
  5. Ongoing management - Monthly refills with clinical monitoring calls

Transfer Instructions: If currently using another specialty pharmacy, your doctor can request a prescription transfer to OptumRx after UnitedHealthcare approval.

Support Lines and Who to Call

Member Support

  • UnitedHealthcare Member Services: Number on your insurance card
  • OptumRx Specialty: 855-427-4682 (24/7)
  • Prior Authorization Status: 1-800-711-4555

Provider Support

  • Provider Services: 1-800-711-4555 (Commercial)
  • Medicare Advantage: Check provider portal for plan-specific numbers
  • Medicaid: 888-397-8129

What to Ask When Calling

  • Current status of your prior authorization request
  • Specific documentation needed if request is incomplete
  • Timeline for decision
  • Appeal rights if denied
  • Expedited review options for urgent cases

Michigan Appeals and External Review

UnitedHealthcare Internal Appeals

Timeline: 180 days from denial date
Levels: Typically 1-2 internal review levels
Expedited: Available for urgent medical situations (72-hour decision)

Michigan DIFS External Review

If UnitedHealthcare's internal appeals are exhausted or unsuccessful:

Timeline: 127 days from final internal denial
Process: Submit DIFS External Review Form (FIS 0018)
Contact: 877-999-6442 (DIFS Consumer Assistance)
Decision: Binding determination within 60 days (72 hours for expedited)

Required Documents for External Review:

  • Completed FIS 0018 form
  • UnitedHealthcare's final denial letter
  • Medical records supporting Xospata necessity
  • Oncologist's letter explaining medical urgency (for expedited review)
Important: Michigan's external review decisions are binding on UnitedHealthcare. If the Independent Review Organization approves coverage, UnitedHealthcare must comply.

Step-by-Step: Fastest Path to Approval

  1. Confirm FLT3 Testing (Patient/Oncologist)
    • Ensure FDA-approved FLT3 mutation test is complete
    • Document ITD or TKD mutation status
    • Timeline: Same day if results available
  2. Gather Prior Treatment History (Oncologist)
    • Document all previous AML therapies
    • Include dates, dosages, outcomes, and discontinuation reasons
    • Timeline: 1-2 days for record compilation
  3. Submit Prior Authorization (Oncologist)
    • Use UnitedHealthcare Provider Portal
    • Upload complete clinical documentation
    • Timeline: Same day submission
  4. UnitedHealthcare Review (Insurer)
    • Standard review: Up to 72 hours
    • Expedited review: Up to 24 hours
    • Timeline: 1-3 business days
  5. If Approved: Specialty Pharmacy Setup (Patient/OptumRx)
    • OptumRx contacts patient for enrollment
    • Insurance verification and copay determination
    • Timeline: 2-5 business days
  6. If Denied: Internal Appeal (Patient/Oncologist)
    • Submit appeal with additional documentation
    • Address specific denial reasons
    • Timeline: 30-60 days for decision
  7. External Review if Needed (Patient)
    • File with Michigan DIFS if internal appeals fail
    • Submit within 127 days of final denial
    • Timeline: Up to 60 days for decision

Common Denial Reasons and Solutions

Denial Reason How to Fix Required Documentation
Missing FLT3 mutation Submit FDA-approved test results Lab report with ITD/TKD confirmation
Inadequate prior therapy Document treatment failures/intolerances Detailed therapy history with outcomes
Step therapy not met Request exception or document contraindications Medical necessity letter with clinical rationale
Non-hematology prescriber Transfer prescription to qualified oncologist Specialist referral and prescription
Investigational use claim Provide FDA labeling and guidelines FDA approval letter, NCCN guidelines

Costs and Patient Assistance

Xospata Pricing: Approximately $28,979 for a 30-day supply (WAC pricing as of January 2025)

Financial Assistance Options:

  • Astellas Patient Assistance: Income-based free drug program
  • Copay assistance cards: May reduce out-of-pocket costs for commercially insured patients
  • State pharmaceutical assistance: Michigan may have additional programs for eligible residents
  • Foundation grants: Organizations like CancerCare and Leukemia & Lymphoma Society offer assistance
Note: Copay assistance typically cannot be used with government insurance (Medicare, Medicaid) but may apply to commercial UnitedHealthcare plans.

FAQ

How long does UnitedHealthcare prior authorization take for Xospata in Michigan? Standard reviews take up to 72 hours, while expedited reviews for urgent cases are completed within 24 hours.

What if Xospata is not on my UnitedHealthcare formulary? Xospata requires prior authorization on most UnitedHealthcare plans but is typically covered. Your doctor can request a formulary exception if needed.

Can I request an expedited appeal in Michigan? Yes, both UnitedHealthcare internal appeals and Michigan DIFS external reviews offer expedited options for urgent medical situations requiring physician documentation.

Does step therapy apply if I've failed treatments outside Michigan? Treatment history from any location counts toward step therapy requirements. Provide complete documentation of prior therapies regardless of where they were received.

What happens if my appeal is denied? After exhausting UnitedHealthcare's internal appeals, you can file for external review with Michigan DIFS within 127 days of the final denial.

Can my family member help with the appeal process? Yes, family members can file appeals on your behalf with proper written authorization. Include the authorization form with your appeal submission.

When Coverage Gets Complicated

Sometimes insurance denials require more than standard appeals. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific basis for denial and craft point-by-point rebuttals. Their platform helps patients, clinicians, and specialty pharmacies get prescription drugs approved by pulling the right citations and weaving them into appeals that meet procedural requirements while tracking deadlines and required documentation.

For complex cases involving multiple denials or unclear coverage criteria, professional advocacy services can help navigate the appeals process more effectively, especially when dealing with UnitedHealthcare's utilization management requirements and Michigan's specific regulatory landscape.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance regarding your coverage and treatment options. For assistance with insurance appeals in Michigan, contact DIFS at 877-999-6442.

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