By Counterforce Health Team in Pemazyre (pemigatinib) —

Lowering Out-of-Pocket for Pemazyre (Pemigatinib) with UnitedHealthcare in New Jersey: Copay, Tiering & Assistance

Answer Box: Getting Pemazyre (Pemigatinib) Covered by UnitedHealthcare in New Jersey

Pemazyre (pemigatinib) requires prior authorization from UnitedHealthcare and is placed on the specialty tier through OptumRx. Your first step is ensuring your oncologist has documented FGFR2 fusion/rearrangement (for cholangiocarcinoma) or FGFR1 rearrangement (for myeloid/lymphoid neoplasms) via molecular testing. If denied, New Jersey offers a robust external review process through IHCAP (Independent Health Care Appeals Program) managed by Maximus Federal Services. Commercial insurance patients can access IncyteCARES copay assistance to reduce out-of-pocket costs to as low as $0 per month.

Start today: Call UnitedHealthcare Member Services (number on your ID card) to confirm your specialty drug benefits and copay responsibility.

Table of Contents

  1. What Drives Your Pemazyre Costs
  2. Investigating Your Benefits
  3. Assistance Options
  4. Requesting Tiering Exceptions
  5. Specialty Pharmacy Requirements
  6. Appeals on Cost Grounds
  7. Annual Renewal Planning
  8. Conversation Scripts

What Drives Your Pemazyre Costs

UnitedHealthcare places Pemazyre on the specialty tier, which typically means you'll pay coinsurance (often 20-33% of the drug cost) rather than a flat copay. For a medication that can cost in the high four to five figures monthly, this translates to substantial out-of-pocket expenses.

Key Cost Factors:

Formulary Placement: Pemazyre requires specialty pharmacy dispensing through OptumRx and prior authorization for all UnitedHealthcare plans.

Medical Necessity Requirements: Coverage depends on documented FGFR alterations confirmed through molecular testing—the most common denial reason when this biomarker evidence is missing.

Site of Care: Must be filled at an OptumRx specialty pharmacy location, not your local retail pharmacy.

Note: UnitedHealthcare's Medicare Advantage plans have shown prior authorization denial rates around 9% (2023), higher than peer averages, making thorough documentation crucial.

Investigating Your Benefits

Before starting treatment, gather specific information about your coverage to avoid surprises.

What to Ask UnitedHealthcare:

  1. "What's my specialty tier coinsurance percentage for 2024?"
  2. "What's my annual out-of-pocket maximum for specialty drugs?"
  3. "Is prior authorization required for Pemazyre, and what documentation do you need?"
  4. "Which OptumRx specialty pharmacies are in-network near me?"
  5. "Are there quantity limits or step therapy requirements?"

Information to Record:

  • Your member ID and group number
  • Specialty drug copay/coinsurance rate
  • Annual deductible remaining
  • Out-of-pocket maximum
  • Prior authorization reference number (once submitted)

Counterforce Health specializes in helping patients navigate complex prior authorization requirements and appeals processes. Their platform can identify specific denial reasons and draft targeted rebuttals using your plan's own coverage policies—particularly valuable for specialty oncology drugs like Pemazyre where biomarker documentation is critical.

Assistance Options

Manufacturer Copay Programs

IncyteCARES for PEMAZYRE offers significant savings for commercially insured patients:

  • Eligible patients may pay as low as $0 per month
  • Commercial insurance required (excludes Medicare, Medicaid, TRICARE)
  • Subject to monthly and annual maximums (contact 1-866-708-8806 for current limits)
  • Enrollment available online or by calling the support line

Foundation Assistance

CancerCare Co-Payment Assistance Fund for cholangiocarcinoma:

  • Currently closed for new applications (as of 2024)
  • When open: up to $8,000 initial grant, potentially $15,000 annually
  • Income limit: 500% of Federal Poverty Level
  • Government insurance required (Medicare, Medicaid, TRICARE)
  • Pre-register for reopening notifications

Case Management Support

Contact your UnitedHealthcare case manager if you have one assigned. They can:

  • Coordinate prior authorization submissions
  • Identify additional cost-sharing reduction programs
  • Help navigate specialty pharmacy requirements
  • Connect you with social work resources

Requesting Tiering Exceptions

If Pemazyre's specialty tier placement creates financial hardship, you can request a formulary exception.

When to Request:

  • Your coinsurance exceeds what you'd pay for a lower-tier alternative
  • No clinically appropriate formulary alternatives exist
  • Lower-tier drugs have failed or caused intolerable side effects

Evidence to Include:

Clinical Documentation:

  • Molecular testing report showing FGFR2 fusion/rearrangement (CCA) or FGFR1 rearrangement (MLN)
  • Prior treatment history and outcomes
  • Letter from oncologist explaining medical necessity

Financial Hardship Documentation:

  • Income verification
  • Statement of financial impact
  • Documentation of other available assistance programs

Submission Process:

Submit through the UnitedHealthcare Provider Portal or have your oncologist call for a peer-to-peer review. Include all supporting documentation with your initial request to avoid delays.

Specialty Pharmacy Requirements

OptumRx Specialty Pharmacy Network is your only option for filling Pemazyre through UnitedHealthcare.

Coordination Tips:

  1. Choose your location early: Ask UnitedHealthcare for in-network specialty pharmacies near you
  2. Set up delivery: Most specialty pharmacies offer overnight shipping at no extra cost
  3. Plan for refills: Specialty pharmacies typically call 5-7 days before you need a refill
  4. Keep backup documentation: Always have your prior authorization number available

Common Coordination Issues:

  • Delays between approval and first fill: Allow 3-5 business days after PA approval
  • Refill timing: Don't wait until you're completely out—specialty drugs can take longer to process
  • Travel considerations: Arrange temporary supplies if traveling; some specialty pharmacies can ship to alternate addresses

Appeals on Cost Grounds

If UnitedHealthcare denies coverage or places Pemazyre in an unaffordable tier, New Jersey offers excellent appeal options.

Internal Appeals Process:

First Level: Submit within 180 days of denial

  • Use UnitedHealthcare member portal or mail written appeal
  • Include medical necessity letter from oncologist
  • Attach molecular testing results and treatment history

Second Level: If first appeal is denied

  • Automatic right to second internal review
  • May request expedited review if treatment delay would cause serious harm

New Jersey External Review (IHCAP):

After completing internal appeals, you have 4 months (180 days) to request external review through the Independent Health Care Appeals Program.

How to Apply:

  • Submit directly to Maximus Federal Services (no longer through NJ DOBI first)
  • [Contact IHCAP at 1-888-393-1062](verify with the source linked below) for forms and guidance
  • Include all denial letters, medical records, and physician statements

Timeline:

  • 5 business days: Preliminary review and acceptance
  • 45 days: Final decision (expedited cases much faster)
  • No cost to you: Insurers pay all review fees
From our advocates: We've seen external reviews succeed when patients include a detailed timeline showing how previous treatments failed and why Pemazyre's specific mechanism (FGFR inhibition) addresses their particular molecular profile. The key is connecting your individual biomarker results to the clinical evidence supporting Pemazyre's effectiveness.

Annual Renewal Planning

Your costs and coverage can change significantly each plan year.

What Changes Annually:

  • Formulary placement: Drugs can move between tiers
  • Copay/coinsurance rates: Your percentage responsibility may increase
  • Prior authorization requirements: Criteria can become more or less restrictive
  • Specialty pharmacy networks: In-network options may change

Renewal Reminders:

October-November: Review your plan's Summary of Benefits for the following year December: If switching plans, ensure new plan covers Pemazyre and your preferred specialty pharmacy is in-network January: Reconfirm prior authorization is still active; some plans require annual renewal

Budget Planning: If you're on IncyteCARES assistance, factor in potential changes to program terms or your insurance benefits that could affect eligibility.

Conversation Scripts

Calling UnitedHealthcare Member Services:

"Hi, I need to understand my specialty drug benefits for Pemazyre, spelled P-E-M-A-Z-Y-R-E. Can you tell me: What tier is it on? What's my coinsurance percentage? Is prior authorization required? And which OptumRx specialty pharmacies are in my network?"

Pharmacy Benefit Inquiry:

"I'm calling about coverage for Pemazyre for [condition]. My doctor says I need prior authorization. Can you walk me through exactly what documentation you need and how long the process typically takes?"

Provider Office Coordination:

"I need help with prior authorization for Pemazyre. My insurance is UnitedHealthcare, and they require documentation of FGFR testing and prior treatment history. Can you help me gather the molecular pathology report and treatment timeline they'll need?"

Requesting Peer-to-Peer Review:

"I'd like to request a peer-to-peer review for my Pemazyre prior authorization. The denial cited [specific reason]. My oncologist has additional clinical information that addresses this concern directly."

Counterforce Health's platform can be particularly valuable for Pemazyre appeals, as it identifies the specific biomarker documentation and clinical evidence that UnitedHealthcare requires, then drafts targeted rebuttals addressing each denial reason point-by-point. This targeted approach is especially important for rare cancer treatments where standard templates often miss crucial specialty-specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and assistance program terms change frequently. Always verify current requirements with your insurance plan, healthcare provider, and relevant assistance programs. For personalized help with New Jersey insurance appeals, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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