By Counterforce Health Team in Retevmo (selpercatinib) —

Myths vs. Facts: Getting Retevmo (Selpercatinib) Covered by UnitedHealthcare in California

Answer Box: Getting Retevmo Covered by UnitedHealthcare in California

The fastest path to Retevmo approval: Submit prior authorization with FDA-approved RET testing results, complete treatment history, and clinical necessity documentation. If denied, file an expedited internal appeal within 21 days, then request California DMHC Independent Medical Review (73% success rate). Your oncologist must document medical urgency for 72-hour expedited review. Start today: Call UnitedHealthcare member services to confirm your specialty pharmacy requirements and initiate prior authorization through your provider.

Table of Contents

Why Myths About Specialty Drug Coverage Persist

When you're facing a cancer diagnosis and need a targeted therapy like Retevmo (selpercatinib), misinformation can cost precious time. Myths about insurance coverage spread because the system is genuinely complex, and well-meaning friends, online forums, and even some healthcare staff may share outdated or incomplete information.

UnitedHealthcare manages Retevmo through OptumRx as a specialty medication requiring prior authorization. In California, you have stronger appeal rights than most states, but only if you know how to use them. Let's separate fact from fiction so you can get the coverage you need.

Common Myths vs. Facts

Myth 1: "If my oncologist prescribes Retevmo, UnitedHealthcare has to cover it"

Fact: Prescription alone doesn't guarantee coverage. UnitedHealthcare requires prior authorization with specific documentation, including FDA-approved RET testing results and treatment history. Even medically necessary drugs can be initially denied due to incomplete paperwork.

Myth 2: "I have to try cheaper alternatives first (step therapy) before getting Retevmo"

Fact: Step therapy may apply, but exceptions exist. If you've already failed or can't tolerate standard therapies, or if they're contraindicated for your specific RET alteration, your oncologist can request an exception. California law supports access to medically necessary treatments even when alternatives exist.

Myth 3: "If UnitedHealthcare denies Retevmo, I'm out of options"

Fact: California has one of the strongest appeal systems in the U.S. After internal appeals, you can request Independent Medical Review (IMR) through the California DMHC, which overturns about 73% of denials for medically necessary treatments.

Myth 4: "Appeals take months and won't help urgent cancer treatment"

Fact: Expedited appeals exist for urgent situations. UnitedHealthcare must decide expedited internal appeals within 72 hours. California DMHC expedited IMR decisions come within 3-7 days when delay would jeopardize health.

Myth 5: "I need a lawyer to appeal insurance denials"

Fact: You can handle appeals yourself with proper documentation. California provides free help through the DMHC Help Center (888-466-2219) and consumer assistance organizations. Legal help may be useful for complex cases, but isn't required.

Myth 6: "Generic alternatives are just as good as Retevmo"

Fact: There's no generic selpercatinib. Alternative RET inhibitors like Gavreto (pralsetinib) exist, but they're also brand-name specialty drugs requiring similar prior authorization. Your oncologist must justify why Retevmo is specifically needed over alternatives.

Myth 7: "If I can't afford the copay, I can't get Retevmo"

Fact: Multiple assistance programs exist. Eli Lilly offers patient support programs, and California law prevents copay accumulator programs from blocking manufacturer assistance. You may also qualify for foundation grants or state programs.

Myth 8: "UnitedHealthcare will automatically approve Retevmo for any RET-positive cancer"

Fact: RET testing must be done with FDA-approved methods like FoundationOne CDx. The specific cancer type, stage, and prior treatments all matter for approval.

What Actually Influences Retevmo Approval

Understanding UnitedHealthcare's actual criteria helps you prepare a strong case:

Required Documentation

  • RET alteration confirmation via FDA-approved testing (FoundationOne CDx, tissue or liquid biopsy)
  • Specific diagnosis with staging (advanced/metastatic NSCLC, medullary thyroid cancer, or RET fusion-positive thyroid cancer)
  • Prior treatment history showing standard therapies tried, failed, or contraindicated
  • Clinical rationale explaining why Retevmo is medically necessary now

Medical Necessity Factors

  • Disease progression on current therapy
  • Intolerance or contraindications to alternatives
  • Performance status supporting oral targeted therapy
  • Monitoring plan for QT prolongation and drug interactions

Submission Quality

Your oncologist's prior authorization request must be complete and specific. Counterforce Health helps clinicians prepare evidence-backed appeals that address payer-specific criteria, turning denials into targeted rebuttals with the right clinical facts and citations.

Avoid These Critical Mistakes

1. Incomplete RET Testing Documentation

Mistake: Submitting results from non-FDA-approved tests or incomplete pathology reports. Fix: Ensure testing used FDA-approved companion diagnostics and include the full pathology report with RET alteration details.

2. Missing Treatment History

Mistake: Not documenting prior therapies attempted or why alternatives aren't appropriate. Fix: Provide detailed records of previous treatments, outcomes, and clinical rationale for each decision.

3. Ignoring Cardiac Monitoring Requirements

Mistake: Not addressing QT prolongation risks in the prior authorization. Fix: Include baseline ECG, electrolyte levels, and monitoring plan in your submission.

4. Missing Appeal Deadlines

Mistake: Waiting too long to appeal denials. Fix: California requires appeals within 21 days for outpatient services. Mark deadlines immediately when you receive denial letters.

5. Not Using Expedited Processes

Mistake: Filing standard appeals when expedited review is appropriate. Fix: If treatment delay risks your health, specifically request expedited review and have your oncologist document medical urgency.

Quick Action Plan: Three Steps to Take Today

Step 1: Verify Your Coverage Requirements

Call UnitedHealthcare member services (number on your insurance card) to confirm:

  • Whether Retevmo requires specialty pharmacy dispensing
  • Your specific prior authorization requirements
  • Current formulary status and tier placement

Step 2: Gather Essential Documentation

Work with your oncology team to collect:

  • FDA-approved RET testing results
  • Complete pathology report
  • Treatment history and outcomes
  • Current staging and performance status
  • Baseline cardiac monitoring (ECG, electrolytes)

Step 3: Initiate Prior Authorization

Have your oncologist submit through the UnitedHealthcare provider portal with complete documentation. If you need help organizing evidence-backed appeals, Counterforce Health specializes in turning insurance denials into targeted, policy-aligned rebuttals.

Resources and Next Steps

UnitedHealthcare Resources

California State Resources

  • DMHC Help Center: 888-466-2219
  • Independent Medical Review applications and guidance
  • Consumer assistance for complex appeals

Clinical Guidelines

Patient Support

  • Eli Lilly Retevmo patient assistance programs
  • Foundation grants for specialty medications
  • California-specific financial assistance resources
From Our Advocates: We've seen cases where patients initially denied for Retevmo received approval after submitting complete RET testing documentation and detailed treatment history. The key is thorough preparation and using California's strong appeal rights when needed. This is a composite example, not a guarantee of outcomes.

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or legal counsel. Always consult with your healthcare team about treatment decisions and consider professional assistance for complex appeals. Coverage policies may change, so verify current requirements with your insurer and state regulators.

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