By Counterforce Health Team in Xospata (gilteritinib) —

How to Get Xospata (Gilteritinib) Covered by UnitedHealthcare in New York: Forms, Appeals, and Provider Contacts

Answer Box: Getting Xospata Covered by UnitedHealthcare in New York

Xospata (gilteritinib) requires prior authorization from UnitedHealthcare for relapsed/refractory FLT3-mutated AML. Key steps: (1) Submit PA via UnitedHealthcare Provider Portal with FLT3 mutation test and prior therapy records, (2) If denied, file internal appeal within 180 days, (3) Request New York external review through Department of Financial Services within 4 months of final denial. Start 3-4 weeks before treatment to allow for review timelines.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Instructions
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Onboarding with Optum
  6. Support Phone Lines and Contacts
  7. New York External Review and Consumer Help
  8. Common Denial Reasons and How to Fix Them
  9. Appeals Playbook for UnitedHealthcare in New York
  10. FAQ: Xospata Coverage in New York

Verify Your Plan and Find the Right Forms

Before starting your Xospata prior authorization, confirm your specific UnitedHealthcare plan type. Requirements differ between commercial plans, Medicare Advantage, and Medicaid managed care.

Check your insurance card for:

  • Plan name (Community Plan, Choice Plus, etc.)
  • Member ID format
  • Pharmacy benefit manager (typically OptumRx)
  • Specialty pharmacy designation
Tip: Log into the UnitedHealthcare member portal to view your specific formulary and PA requirements. Your plan documents will specify whether Xospata is covered under medical or pharmacy benefits.

Prior Authorization Forms and Requirements

Coverage at a Glance

Requirement Details Where to Find Source
PA Required? Yes, for all plan types Provider Portal PA&N tool UHC PA Requirements
Formulary Tier Specialty tier (varies by plan) Member portal > Prescription Drug List Plan-specific formulary
FLT3 Testing FDA-approved test required Lab report with mutation type FDA Access Data
Prescriber Type Oncologist/hematologist preferred Medical license verification UHC policy
Appeals Deadline 180 days from denial Denial letter UHC Appeals Process

Required Clinical Documentation

Submit these documents with your PA:

  1. FLT3 Mutation Test Results
    • FDA-approved test confirming ITD or TKD mutation
    • Include mutation type and percentage if available
  2. Prior Therapy Documentation
    • Treatment dates and regimens
    • Response assessment and reason for discontinuation
    • Documentation of relapsed or refractory disease
  3. Current Clinical Status
    • Recent bone marrow biopsy results
    • ECOG performance status
    • Complete blood count and metabolic panel
  4. Medical Necessity Letter
    • Diagnosis confirmation with ICD-10 codes
    • Treatment goals and expected duration
    • Contraindications to alternative therapies
Clinician Corner: Include NCCN guideline references in your medical necessity letter. Xospata is recommended as a Category 1 therapy for relapsed/refractory FLT3-mutated AML in adults.

Submission Portals and Upload Instructions

UnitedHealthcare Provider Portal

Primary submission method: UnitedHealthcare Provider Portal

Step-by-step submission:

  1. Log in with your One Healthcare ID
  2. Navigate to "Prior Authorization and Notification" (PA&N)
  3. Select "New Prior Authorization Request"
  4. Enter member information and Xospata details (NDC: varies by strength)
  5. Upload all required clinical documents
  6. Submit and note the reference number

Required portal access:

  • One Healthcare ID registration
  • Provider credentialing with UnitedHealthcare
  • Access to "Specialty Pharmacy Transactions" for medical benefit drugs

Alternative Submission Methods

OptumRx Phone/Fax:

  • Phone: 888-397-8129
  • Fax: (verify current number in provider portal)
  • Use for urgent cases or portal technical issues

Timeline expectations:

  • Initial review: 5-15 business days
  • Peer-to-peer review: 2-5 additional days
  • Expedited review: 72 hours (urgent cases only)

Fax Numbers and Mailing Addresses

Key UnitedHealthcare Contacts

Purpose Contact Method Details
Prior Authorization Portal preferred UHC Provider Portal
Urgent Appeals Fax: 800-267-8328 Community Plan/DSNP only
Provider Services Phone: 877-842-3210 General inquiries
Medicaid Appeals Email: [email protected] Medicaid/CHP+ only

Cover Sheet Best Practices

When faxing documentation:

  • Include member ID, provider NPI, and urgent designation if applicable
  • List all attached documents
  • Include direct callback number
  • Mark "CONFIDENTIAL MEDICAL INFORMATION"

Specialty Pharmacy Onboarding with Optum

Most UnitedHealthcare plans require Xospata to be filled through Optum Specialty Pharmacy. Here's the onboarding process:

Step-by-Step Onboarding

  1. Prescription Routing
    • E-prescribe directly to Optum Specialty Pharmacy
    • Include diagnosis and FLT3 mutation status in notes
  2. Benefits Verification
    • Optum verifies UHC coverage and PA status
    • Confirms specialty pharmacy requirement
  3. Patient Intake
    • Optum contacts patient within 24-48 hours
    • Collects shipping address and consent
    • Reviews potential drug interactions
  4. Financial Assessment
    • Screens for manufacturer copay assistance
    • Explores foundation grants if applicable
    • Confirms patient financial responsibility
  5. Shipment Coordination
    • Temperature-controlled delivery to home or office
    • Provides tracking information and care management

Transferring from Another Pharmacy

If transferring an existing Xospata prescription:

  • Have prescriber send new prescription to Optum
  • Optum can coordinate remaining refills from previous pharmacy
  • Maintain 1-2 weeks of medication supply during transfer
  • Confirm PA approval transfers with new benefit

Support Phone Lines and Contacts

Member Services (Plan-Specific)

General UnitedHealthcare: Check your member ID card for plan-specific numbers

UnitedHealthOne/Individual Plans: 800-657-8205

  • Live support: Mon-Fri 7 a.m.-5 p.m. CT
  • TTY: 711

Provider Support

Provider Services: 877-842-3210

  • PA status inquiries
  • Peer-to-peer review requests
  • Appeals assistance

OptumRx Specialty: 855-473-8889

  • Specialty pharmacy questions
  • Prescription status
  • Patient onboarding support

What to Ask When Calling

For PA status:

  • "I need to check the status of a prior authorization for Xospata (gilteritinib)"
  • Have ready: Member ID, provider NPI, PA reference number

For appeals:

  • "I need to file an internal appeal for a Xospata denial"
  • Request: Appeal form, submission deadline, required documentation

New York External Review and Consumer Help

New York Department of Financial Services External Appeal

If UnitedHealthcare issues a final denial after internal appeals, New York residents can request an independent external review.

Eligibility:

  • Final adverse determination from UHC
  • Denial based on medical necessity, experimental/investigational status, or formulary exception
  • Filed within 4 months of final denial

Required Form: New York State External Appeal Application (EA 04/23)

Submit to: New York State Department of Financial Services 99 Washington Avenue, Box 177 Albany, NY 12210

Expedited Review: For urgent cases, fax application and call 1-888-990-3991

Consumer Assistance Program

Community Health Advocates (CHA) provides free help with insurance denials and appeals in New York.

Services include:

  • Explaining denial reasons and appeal rights
  • Completing DFS external appeal applications
  • Coordinating with prescribing physicians
  • Fee waiver assistance for financial hardship

Contact: Search "New York Consumer Assistance Program Community Health Advocates" or call the DFS consumer helpline for current contact information.

Common Denial Reasons and How to Fix Them

Denial Reason Required Fix Documentation Needed
Missing FLT3 test Submit FDA-approved test results Lab report with mutation type (ITD/TKD)
Front-line use Document relapsed/refractory status Prior therapy records and response assessment
Non-oncology prescriber Transfer to hematologist/oncologist New prescription from specialist
Step therapy required Document failure of preferred agents Treatment history with dates and outcomes
Quantity limit exceeded Provide clinical justification Dosing rationale and treatment plan

Medical Necessity Letter Template

Your oncologist's letter should include:

  1. Patient diagnosis: Relapsed/refractory AML with FLT3 mutation (specify ITD or TKD)
  2. Prior treatments: List all previous therapies with dates and outcomes
  3. Clinical rationale: Why Xospata is appropriate for this patient
  4. Alternative consideration: Why other options are unsuitable
  5. Treatment goals: Expected duration and monitoring plan

Appeals Playbook for UnitedHealthcare in New York

Internal Appeals Process

Level 1: Standard Appeal

  • Deadline: 180 days from denial date
  • Timeline: 30 days for pre-service, 60 days for post-service
  • Submission: Provider portal, fax, or mail per denial letter

Level 2: Second-Level Review

  • Automatic: If Level 1 upholds denial
  • Timeline: Additional 30-60 days
  • Includes: Clinical peer review if applicable

External Review (New York)

After final internal denial:

  • Deadline: 4 months from final adverse determination
  • Form: DFS External Appeal Application
  • Fee: Up to $25 (waived for Medicaid/hardship)
  • Timeline: 30 days standard, 72 hours expedited

Expedited external review criteria:

  • Serious jeopardy to health if delayed
  • Physician attestation required
  • Call DFS at 1-888-990-3991 after faxing

FAQ: Xospata Coverage in New York

Q: How long does UnitedHealthcare PA take in New York? A: Standard review takes 5-15 business days. Expedited review (for urgent cases) is completed within 72 hours.

Q: What if Xospata is non-formulary on my plan? A: Request a formulary exception through the PA process. Include medical necessity documentation showing why formulary alternatives are inappropriate.

Q: Can I get expedited review for Xospata? A: Yes, if your oncologist attests that waiting for standard review would seriously jeopardize your health. Submit via provider portal with "urgent" designation.

Q: Does step therapy apply if I've failed treatments outside New York? A: Prior therapy from any location counts. Submit complete treatment records showing failure or intolerance of required first-line agents.

Q: What's the cost with UnitedHealthcare coverage? A: Costs vary by plan. Xospata's wholesale price is approximately $28,979 for a 30-day supply. Check your plan's specialty tier copay and consider manufacturer assistance programs.

Q: Can I appeal if my oncologist isn't in-network? A: Yes, you can request an out-of-network exception if no in-network specialists are available or appropriate for your condition.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes for specialty medications like Xospata. Our platform analyzes denial letters, identifies specific appeal strategies, and generates evidence-backed responses tailored to each payer's requirements. Learn more about our services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may vary by plan and can change. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For personalized assistance with insurance denials and appeals, consider contacting Counterforce Health or New York's Consumer Assistance Program.

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