By Counterforce Health Team in Arikayce (amikacin liposome inhalation) —

Resources to Get Arikayce Covered by UnitedHealthcare in Texas: Complete Forms, Portals & Contact Guide

Answer Box: Getting Arikayce Covered by UnitedHealthcare in Texas

Eligibility: Arikayce requires prior authorization through UnitedHealthcare for refractory MAC lung disease after 6+ months of failed multidrug therapy. Fastest approval path: Submit PA via UnitedHealthcare Provider Portal with complete clinical documentation showing culture-positive MAC despite standard treatment. First step today: Verify your plan type (commercial vs. Medicare vs. Medicaid) and gather medical records documenting failed MAC treatment. Standard review takes 7-14 days; expedited review available for urgent cases within 72 hours.

Table of Contents

Start Here: Verify Your Plan

Before submitting any paperwork, confirm which UnitedHealthcare plan you have, as requirements differ:

Commercial Plans: Use OptumRx prior authorization process with standard 7-14 day review timeline.

Medicare Advantage: Follow Medicare Part D procedures; may include step therapy requirements starting 2026.

Texas Community Plan (Medicaid/CHIP): Fax documentation to 866-940-7328 with 24-hour determination timeline.

Tip: Log into your UnitedHealthcare member portal or call the number on your insurance card to verify your specific plan type and pharmacy benefits manager.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Diagnosis MAC lung disease with positive cultures Medical records, culture results UHC PA Criteria
Failed Treatment 6+ months multidrug therapy without culture clearance Treatment history, dates, medications tried UHC PA Criteria
Combination Use Must be part of multi-drug regimen Current medication list UHC PA Criteria
Initial Authorization 6 months coverage Complete PA submission UHC PA Notification
Reauthorization 12 months if criteria met Culture results or clinical benefit documentation UHC PA Criteria

Forms & Documentation

Required Clinical Documentation

Medical Necessity Letter must include:

  • MAC lung disease diagnosis with ICD-10 codes
  • Detailed treatment history: specific medications, doses, duration (minimum 6 months)
  • Culture results showing persistent MAC positivity
  • Amikacin susceptibility testing (MIC <64 mcg/mL recommended)
  • Current combination regimen plan
  • Provider attestation and signature

Supporting Documents:

  • Recent chest imaging (CT scan preferred)
  • Pulmonary function tests
  • Complete medication history
  • Laboratory results including culture and sensitivity
Clinician Corner: UnitedHealthcare specifically requires documentation that the patient "has not achieved negative sputum cultures after a minimum of 6 consecutive months of multidrug background regimen therapy within the past 12 months." Include exact dates and specific medications tried.

Plan-Specific Forms

Commercial Plans: Use UnitedHealthcare Provider Portal electronic submission or download forms from UHC Provider Resources.

Texas Medicaid/CHIP: Submit via standard PA request form or use Texas-specific documentation requirements.

Medicare Plans: May require additional Medicare Part D forms; verify current requirements through plan documents.

Submission Portals & Methods

Electronic Submission (Preferred)

UnitedHealthcare Provider Portal:

  • Log in at uhcprovider.com
  • Navigate to "Specialty Pharmacy Transactions"
  • Upload all required documentation
  • Track submission status in real-time

Alternative Electronic Options:

  • CoverMyMeds platform
  • PreCheck MyScript (EMR-integrated)
  • Direct EMR integration where available

Phone Submission

OptumRx Prior Authorization: 1-800-711-4555

  • Available for immediate PA questions
  • Can initiate PA process over phone
  • Business hours: Monday-Friday, standard business hours

Contact Numbers & Fax Lines

Texas-Specific Contacts

Texas Community Plan (Medicaid/CHIP):

  • PA Fax: 866-940-7328
  • Pharmacy Help Desk: 800-310-6826 (Mon-Fri 7am-7pm CT)
  • Customer Service: 888-887-9003
  • After-hours assistance: 877-305-8952

Commercial Plans:

  • OptumRx PA Department: 1-800-711-4555
  • Medical Benefit Injectables: 888-397-8129 (Mon-Fri 7am-7pm CT)
  • Email: [email protected]

Medicare Plans:

  • Use standard Medicare customer service numbers on member ID card
  • OptumRx handles pharmacy benefit PAs: 1-800-711-4555
Note: Fax cover sheets should include patient name, date of birth, member ID, prescriber name, and "URGENT - ARIKAYCE PRIOR AUTHORIZATION" for expedited processing.

Appeals Process in Texas

Step-by-Step Appeals Process

1. Internal Appeal (Required First Step)

  • Timeline: File within 180 days of denial notice
  • Method: UnitedHealthcare Provider Portal, phone, or written submission
  • Decision: 30 days for pre-service, 60 days for post-service
  • Expedited: 72 hours for urgent medical situations

2. External Review (Texas Residents)

  • Eligibility: Available after internal appeal denial
  • Timeline: File within 4 months of final internal denial
  • Process: Texas Department of Insurance Independent Review Organization
  • Decision: 20 days standard, 5 days expedited
  • Cost: Free to patient/provider

3. Federal External Review (ACA Plans)

  • Process: MAXIMUS Federal Services handles most ACA marketplace plans
  • Contact: 1-888-866-6205
  • Address: MAXIMUS Federal Services, 3750 Monroe Ave Suite 705, Rochester, NY
  • Timeline: 45 days standard, 72 hours expedited

When External Review Applies

Texas law provides external review rights for denials based on:

  • Medical necessity
  • Appropriateness of care
  • Experimental/investigational treatment determinations

Important: ERISA self-funded employer plans follow federal appeals rules, not Texas state law.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient treatment history Document complete 6-month trial history Pharmacy records, prescription history, provider notes
Missing culture results Provide recent positive MAC cultures Laboratory reports within 6 months
Lack of combination therapy Specify current multidrug regimen Current medication list with doses
Step therapy not met Request exception with medical necessity Prior therapy failure documentation
Non-formulary status Submit formulary exception request Medical necessity letter, alternative contraindications

Counterforce Health Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps identify the specific denial basis and drafts point-by-point responses aligned with UnitedHealthcare's own coverage rules, potentially saving weeks of back-and-forth communications.

Texas External Review Rights

Texas Department of Insurance Process

Filing an External Review:

  • Online: TDI IRO Request System for providers
  • Phone: 1-800-252-3439 for consumer assistance
  • Forms: Available at tdi.texas.gov

Review Process:

  • Independent medical experts review case
  • Decision is binding on UnitedHealthcare
  • No cost to patient or provider
  • Expedited review available for urgent cases

Important Limitations:

  • Must exhaust internal appeals first (except life-threatening situations)
  • Only applies to fully insured plans regulated by Texas
  • Self-funded ERISA plans use federal external review

Federal External Review (ACA/Marketplace Plans)

Most UnitedHealthcare ACA marketplace plans use the federal external review process through MAXIMUS Federal Services. The insurer must provide external review forms with final denial notices.

Support Resources

Texas Consumer Assistance

Texas Department of Insurance:

  • Consumer Helpline: 1-800-252-3439
  • Website: tdi.texas.gov
  • Services: Appeals guidance, complaint filing, plan information

Office of Public Insurance Counsel (OPIC):

  • Helpline: 1-877-611-6742
  • Services: Consumer advocacy, appeals assistance, educational resources

Specialty Pharmacy Support

UnitedHealthcare Specialty Pharmacy Network:

  • Direct shipment to home or clinic
  • Insurance billing handled directly
  • Clinical support and monitoring
  • Patient education and adherence programs

For specialty pharmacy enrollment, contact your prescriber or UnitedHealthcare customer service for network pharmacy options.

Financial Assistance

Insmed Patient Support Program:

  • Copay assistance for eligible patients
  • Prior authorization support
  • Nurse case management
  • Financial hardship programs

Contact Insmed directly for current program availability and eligibility requirements.

FAQ

How long does UnitedHealthcare prior authorization take for Arikayce in Texas? Standard review takes 7-14 days for commercial plans, 24 hours for Texas Medicaid/CHIP. Expedited review available within 72 hours for urgent medical situations.

What if Arikayce is not on my formulary? Request a formulary exception as part of your prior authorization, providing medical necessity documentation showing why covered alternatives are inappropriate or contraindicated.

Can I request an expedited appeal in Texas? Yes, expedited appeals are available when delays would jeopardize your health. Both internal and external reviews offer expedited timelines (72 hours internal, 5 days external for Texas IRO).

Does step therapy apply to Arikayce? Current UnitedHealthcare policies don't explicitly list step therapy requirements for Arikayce, but Medicare Advantage plans may implement step therapy protocols starting 2026. Check your specific plan documents.

What happens if my internal appeal is denied? You have 4 months to file for external review through either Texas Department of Insurance (fully insured plans) or federal external review (ACA/marketplace plans). The external review decision is binding on UnitedHealthcare.

Who can help me navigate the appeals process? Texas Department of Insurance (1-800-252-3439), Office of Public Insurance Counsel (1-877-611-6742), and Counterforce Health provide specialized appeals assistance for complex specialty drug denials.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For official appeals assistance in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.