By Counterforce Health Team in Dupixent (dupilumab) —

Requirements Checklist to Get Dupixent (dupilumab) Covered by UnitedHealthcare in Ohio: Forms, Appeals, and Cost-Saving Strategies

Answer Box: Ohio patients need prior authorization through OptumRx for Dupixent coverage by UnitedHealthcare. Submit via provider portal with diagnosis documentation, step therapy failures (topicals for atopic dermatitis, high-dose ICS/LABA for asthma), and medical necessity letter. If denied, appeal within 21 days internally, then external review through Ohio Department of Insurance within 180 days. Start with UnitedHealthcare provider portal today.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria by Indication
  4. Coding & Documentation Requirements
  5. Submission Process
  6. Specialty Pharmacy Routing
  7. After Submission: Tracking & Timeline
  8. Appeals Process for Ohio Residents
  9. Common Denial Reasons & How to Avoid Them
  10. Cost-Saving Strategies
  11. Quick Reference Checklist

Who Should Use This Checklist

This guide helps Ohio patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Dupixent (dupilumab). You'll need this if:

  • Your doctor prescribed Dupixent for atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, prurigo nodularis, or COPD
  • You have UnitedHealthcare coverage (commercial, Medicare Advantage, or exchange plans)
  • Your pharmacy informed you that prior authorization is required
  • You received a denial and need to appeal

Expected outcome: Following this checklist increases your approval chances significantly. UnitedHealthcare's OptumRx requires prior authorization for all Dupixent prescriptions, but proper documentation typically leads to approval within 72 hours.

Member & Plan Basics

Coverage Requirements

Requirement Details Source
Prior Authorization Required for all UnitedHealthcare plans UHC PA Notification
Formulary Status Preferred on most plans, Tier 3-4 specialty OptumRx Formulary
Quantity Limits Varies by indication and dosing UHC PA Requirements
Step Therapy Required for most indications UHC Medical Necessity

Plan Types Covered

  • Commercial employer plans (most common in Ohio)
  • Individual/family marketplace plans
  • Medicare Advantage with prescription drug coverage
  • Medicare Part D standalone plans
Note: Self-funded employer plans follow federal ERISA rules but often use similar processes.

Clinical Criteria by Indication

Atopic Dermatitis (Most Common)

Required Documentation:

  • Moderate-to-severe atopic dermatitis diagnosis (ICD-10: L20.9)
  • Prior therapy with topical corticosteroids
  • Trial of topical calcineurin inhibitors or PDE4 inhibitors (like Eucrisa)
  • Critical restriction: No concurrent biologics or JAK inhibitors

Step Therapy: Minimal compared to other conditions. Document specific failure reasons (lack of efficacy, adverse events, contraindications).

Asthma (Stricter Requirements)

Required Documentation:

  • Eosinophilic phenotype: Blood eosinophils ≥150 cells/μL OR oral corticosteroid dependence
  • Maximum dose inhaled corticosteroid (ICS) plus long-acting beta-agonist (LABA)
  • Poor control demonstrated by: ACQ score >1.5, ACT score <20, ≥2 systemic steroid bursts in past year, or reduced FEV1
  • Specialist involvement (allergist, immunologist, or pulmonologist) preferred

COPD (If Applicable)

Required Documentation:

  • Higher eosinophil threshold: ≥300 cells/μL (not 150)
  • Post-bronchodilator FEV1/FVC <0.7 and FEV1 30-70% predicted
  • Uncontrolled disease: ≥2 exacerbations requiring steroids/antibiotics or 1 hospitalization >24 hours

Coding & Documentation Requirements

ICD-10 Codes

Indication Primary Codes Secondary Options
Atopic Dermatitis L20.9 (unspecified) L20.89 (other)
Asthma J45.50 (unspecified) J45.909 (severe persistent)
CRSwNP J32.4, J33.9 -
EoE K20.0 -
Prurigo Nodularis L28.1 -

Billing Information

  • HCPCS J-Code: J3590 (unclassified biologics)
  • NDC Examples: 59212-0025-01 (100mg), 59212-0029-01 (300mg)
  • Billing Units: 1 unit = 10mg (300mg dose = 30 units)
  • Modifiers: JW for wastage >10%

Dosing by Indication

Condition Loading Dose Maintenance Frequency
Atopic Dermatitis 600mg 300mg Every 2 weeks
Asthma 400mg or 600mg 200mg or 300mg Every 2 weeks
CRSwNP 300mg 300mg Every 2 weeks

Submission Process

Step-by-Step Submission

  1. Provider Portal Access: Log into UnitedHealthcare Provider Portal
  2. Form Selection: Use current Dupixent PA form (verify version date)
  3. Required Fields: Patient demographics, diagnosis codes, dosing, medical necessity
  4. Attachments: Medical necessity letter, lab results, prior therapy documentation
  5. Submission Method: Electronic submission mandatory since June 2025
Tip: Use CoverMyMeds for real-time PA processing if your practice has access.

Medical Necessity Letter Components

Essential Elements:

  • Patient's specific diagnosis and severity measures
  • Complete prior therapy history with dates and outcomes
  • Clinical rationale for Dupixent selection
  • Expected benefits and monitoring plan
  • Supporting literature citations (FDA labeling, guidelines)
Clinician Corner: Include objective measures like EASI scores for atopic dermatitis or ACQ/ACT scores for asthma. Document specific reasons for prior therapy failures—"patient switched" isn't sufficient. Reference FDA prescribing information for indication-specific dosing and contraindications.

Specialty Pharmacy Routing

Preferred Vendors

UnitedHealthcare routes Dupixent through preferred specialty pharmacies:

  • Optum Specialty Pharmacy (primary)
  • Accredo
  • Walgreens Specialty Pharmacy
  • Caremark Specialty

Process After Approval

  1. Enrollment: Provider submits enrollment forms to assigned specialty pharmacy
  2. Benefits Verification: Pharmacy confirms coverage and copay
  3. Patient Contact: Pharmacy calls patient for delivery scheduling
  4. Shipment: 2-3 day delivery with temperature monitoring
  5. Training: Injection training provided if needed

After Submission: Tracking & Timeline

Review Timeline

  • Standard Review: 72 hours
  • Expedited Review: 24 hours (requires physician certification of urgency)
  • Reauthorization: Annual renewal required 30 days before expiration

Status Tracking

  • Confirmation Number: Record for all submissions
  • Portal Checks: Monitor status daily during review period
  • Contact Info: OptumRx specialty support at 1-855-427-4682

What to Record

  • Submission date and confirmation number
  • Assigned case number
  • Review timeline communicated
  • Any requests for additional information

Appeals Process for Ohio Residents

Internal Appeals (Required First)

Timeline: 21 calendar days from denial notice Method: UnitedHealthcare Provider Portal (electronic submission required) Response Time: 5-10 business days (standard) or 72 hours (urgent)

Required Documentation:

  • Original denial letter
  • Updated medical necessity letter addressing denial reasons
  • Additional clinical evidence
  • Peer-to-peer review notes (if conducted)

External Review Through Ohio Department of Insurance

When to Use: After exhausting internal appeals for medical necessity denials Timeline to File: 180 days from final internal denial Cost: Free to consumers

Process:

  1. Contact ODI: Call 1-800-686-1526 or visit insurance.ohio.gov
  2. Submit Request: Complete external review form
  3. IRO Assignment: Independent Review Organization assigned within 5 days
  4. Decision Timeline: 30 days standard, 72 hours expedited
  5. Binding Decision: IRO decision binding on UnitedHealthcare
Ohio Advantage: Even if UnitedHealthcare claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

Common Denial Reasons & How to Avoid Them

Denial Reason Prevention Strategy Documentation Needed
Incomplete step therapy Document specific failure reasons and dates Prior therapy records with outcomes
Missing eosinophil count Include recent lab results (within 6 months) CBC with differential
Lack of severity documentation Use validated scoring tools EASI scores, ACQ/ACT scores
Concurrent prohibited therapy Verify no biologics/JAK inhibitors Current medication list
Insufficient specialist involvement Obtain referral for complex cases Specialist consultation notes

Five Common Pitfalls

  1. Generic failure statements: "Patient didn't respond" vs. "Patient used fluticasone 0.05% cream twice daily for 8 weeks with <25% improvement in EASI score"
  2. Missing lab values: Always include recent eosinophil counts for asthma/COPD
  3. Outdated forms: Verify you're using the current PA form version
  4. Incomplete contact info: Ensure accurate prescriber NPI and contact information
  5. Timing errors: Submit renewals 30 days before expiration, not after

Cost-Saving Strategies

Manufacturer Support

Dupixent MyWay Program:

  • Commercial insurance: $0 copay (up to $13,000 annually)
  • Eligibility: No government insurance (Medicare/Medicaid excluded)
  • Contact: 1-844-387-4936
  • Website: dupixent.com/support-savings

Additional Resources

  • Quick Start Program: Free 30-day supply during PA processing
  • Foundation Grants: Patient advocate organizations for uninsured
  • Ohio Medicaid: Coverage available with prior authorization

2025 Medicare Changes

Medicare Part D: $2,000 annual out-of-pocket cap applies to UnitedHealthcare Medicare plans, significantly reducing costs for eligible patients.

Quick Reference Checklist

Before Starting:

  • Active UnitedHealthcare coverage verified
  • Current prescription from qualified prescriber
  • Diagnosis documentation with ICD-10 codes
  • Prior therapy records with specific failure reasons
  • Recent lab results (eosinophil count if applicable)
  • Specialist consultation notes (for complex cases)

During Submission:

  • Current PA form version used
  • All required fields completed
  • Medical necessity letter attached
  • Supporting documentation included
  • Confirmation number recorded

After Submission:

  • Status checked within 48 hours
  • Response timeline documented
  • Specialty pharmacy enrollment completed (if approved)
  • Appeal prepared (if denied)

About Counterforce Health: Counterforce Health helps patients and providers turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft evidence-backed rebuttals. Our platform identifies specific denial reasons and creates targeted appeals aligned with each payer's requirements, significantly improving approval rates for specialty medications like Dupixent.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not replace medical advice. Coverage decisions depend on individual circumstances and plan details. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For appeals assistance in Ohio, contact the Ohio Department of Insurance at 1-800-686-1526.

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