By Counterforce Health Team in Krystexxa (pegloticase) —

Resources to Get Krystexxa (Pegloticase) Approved with UnitedHealthcare in Washington: Complete Forms, Portals & Contact Directory

Answer Box: Getting Krystexxa Covered by UnitedHealthcare in Washington

Krystexxa (pegloticase) requires prior authorization through OptumRx for UnitedHealthcare plans in Washington. Submit via the UnitedHealthcare Provider Portal with documented failure of xanthine oxidase inhibitors (allopurinol ≥300mg daily, febuxostat), persistent serum uric acid >6 mg/dL, G6PD testing, and rheumatologist oversight. If denied, Washington residents have strong appeal rights including external review through an Independent Review Organization (IRO) within 180 days. First step: Call UnitedHealthcare member services (number on your ID card) to verify your exact plan type and download the current prior authorization form.

Table of Contents

  1. Start Here: Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Online Tools
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Network
  6. Support Phone Lines & Case Management
  7. Washington State Appeals & Consumer Protection
  8. Update Schedule: When to Re-Check Resources

Start Here: Verify Your Plan & Find the Right Forms

Before submitting any paperwork, confirm your exact UnitedHealthcare plan type and benefit structure. This determines which forms you'll need and which approval pathway applies.

Plan Verification Checklist

Call the member services number on your UnitedHealthcare ID card and ask:

  • Is Krystexxa covered under medical benefit (provider-administered) or pharmacy benefit?
  • Which prior authorization form applies to my specific plan (commercial, Medicare Advantage, Washington Community Plan)?
  • What's my formulary tier for Krystexxa, and are there quantity limits?
  • Do I need specialty pharmacy coordination through OptumRx?
Tip: Have your member ID, group number, and prescribing physician's NPI ready when you call.

Plan-Specific Resources

Commercial Plans: Use the UnitedHealthcare Provider Portal for PA submissions and status tracking.

Medicare Advantage: Follow Medicare Part B guidelines for provider-administered drugs; expedited appeals available for urgent cases.

Washington Community Plan (Medicaid): Download state-specific pharmacy prior authorization forms from the Washington UHC Community Plan page.

Prior Authorization Forms & Requirements

Core PA Requirements for Krystexxa

Based on UnitedHealthcare's Krystexxa policy, all requests must document:

Requirement Documentation Needed Source
FDA-approved indication Chronic gout diagnosis (ICD-10: M10.9) UHC Policy
Refractory to conventional therapy 6+ months allopurinol ≥300mg daily OR febuxostat ≥80mg daily with documented failure/intolerance UHC Policy
Persistent hyperuricemia Serum uric acid >6 mg/dL despite maximum tolerated therapy UHC Policy
G6PD screening Normal G6PD levels (deficiency is contraindication) FDA Label
Specialist oversight Rheumatologist or nephrologist prescription UHC Policy
Infusion capability Administration site equipped for anaphylaxis management UHC Policy

Current Forms (2024-2025)

General PA Form: Download the General UHC Prior Authorization Form for most commercial plans.

Washington Community Plan: Use the Washington-specific pharmacy PA forms available on the UHC Washington provider page.

Electronic Submission: The OptumRx PreCheck Prior Authorization tool can automate submissions for qualifying drugs, reducing processing time to ~30 seconds when criteria are clearly met.

Note: Forms are updated regularly. Always verify you have the current version before submitting.

Submission Portals & Online Tools

Primary Submission Methods

UnitedHealthcare Provider Portal

  • URL: uhcprovider.com
  • Access: Requires provider registration; patients should ask their rheumatologist's office to submit
  • Features: Real-time PA status tracking, document upload, automated notifications
  • Processing Time: 72 hours standard, 24 hours expedited

OptumRx Specialty Pharmacy Portal

  • For plans with pharmacy benefit coverage
  • Integrated with UHC provider portal for seamless transitions
  • Supports bulk document uploads including labs, imaging, and clinical notes

Required Documentation Upload

When submitting through online portals, attach:

  • Clinical notes with gout history and treatment failures
  • Laboratory results showing serum uric acid trends and G6PD status
  • Prior therapy documentation with specific doses, durations, and outcomes
  • Prescriber attestation confirming monitoring protocols and anaphylaxis preparedness

Fax Numbers & Mailing Addresses

UnitedHealthcare PA Fax Lines

General Prior Authorization Fax: 1-844-403-1027

OptumRx Specialty Pharmacy Fax: (verify current number with OptumRx customer service at 1-800-356-3477)

Cover Sheet Requirements

Include on all fax submissions:

  • Patient name and UHC member ID
  • Provider name and NPI
  • Drug name (Krystexxa/pegloticase) and HCPCS code (J2507)
  • Urgency level (standard vs. expedited)
  • Total pages being transmitted
Tip: Call to confirm fax receipt within 24 hours, especially for time-sensitive requests.

Specialty Pharmacy Network

UnitedHealthcare-Contracted Specialty Pharmacies

For Krystexxa dispensing and coordination, UnitedHealthcare contracts with:

  • Optum Specialty Pharmacy (primary for most plans)
  • Accredo Health Group
  • CVS Specialty (Caremark)

Infusion Network Partners

UnitedHealthcare recognizes these infusion providers for Krystexxa administration:

  • Option Care Health
  • IVX Health
  • Optum Infusion Services
  • AleraCare
  • CarePoint Infusion Center

Finding Washington Locations: Use the Amgen Krystexxa infusion center locator to identify nearby sites, then verify UnitedHealthcare network status by calling the provider directly.

Specialty Pharmacy Onboarding

  1. Prescription Transfer: Your rheumatologist sends the Krystexxa prescription to the assigned specialty pharmacy
  2. Insurance Verification: Pharmacy confirms PA approval and benefit details
  3. Financial Screening: Review copay assistance programs and patient support options
  4. Delivery Coordination: Schedule shipment to your chosen infusion center
  5. Ongoing Support: Access to specialty pharmacists and nurse case managers

Support Phone Lines & Case Management

Member Support Numbers

Optum Specialty Pharmacy: 1-855-427-4682 (24/7)

  • Rare disease medication support
  • Financial assistance screening
  • Condition-specific nursing support

OptumRx General Support: 1-800-356-3477 (24/7)

  • Pharmacy benefit questions
  • Home delivery coordination
  • Generic/formulary inquiries

UnitedHealthcare Member Services: Number on your ID card

  • Plan-specific benefit verification
  • Appeals and grievances
  • Case management enrollment

Provider Support Lines

Specialty Guidance Program: 1-888-397-8129 (Mon-Fri, 7 AM-7 PM CT)

  • Prior authorization assistance for providers
  • Medical necessity consultations
  • Peer-to-peer review scheduling
  • Email: [email protected]

General Provider Services: 877-842-3210

  • Claims and eligibility inquiries
  • Provider portal technical support
  • Appeal status updates

Case Management Services

For complex cases requiring Krystexxa, ask about enrollment in:

  • Rare Disease Case Management Programs
  • Complex Care Coordination
  • Nurse Navigator Services

These programs provide dedicated support throughout your treatment journey, helping coordinate between specialists, infusion centers, and insurance approvals.

Washington State Appeals & Consumer Protection

Washington residents have robust appeal rights when UnitedHealthcare denies Krystexxa coverage. The state's external review process is particularly strong for rare disease medications.

Internal Appeals Process

Timeline: 180 days from denial notice to file internal appeal Levels: Most UHC plans offer 1-2 internal appeal levels Expedited Reviews: Available for urgent medical situations (72-hour decision)

External Review (IRO Process)

After exhausting internal appeals, Washington law (RCW 48.43.535) provides access to Independent Review Organizations.

Timeline: 180 days from final internal denial Process: Submit request to Washington Office of Insurance Commissioner Decision Timeline: 30 days standard, 72 hours expedited Binding: IRO decisions are legally binding on UnitedHealthcare

Washington Insurance Commissioner Support

Consumer Advocacy Hotline: 1-800-562-6900 (8:30 AM-4:30 PM, Mon-Fri)

  • Free assistance with insurance disputes
  • Help filing external review requests
  • Complaint investigation services

Online Resources: insurance.wa.gov

  • Appeal templates and guidance
  • Consumer rights information
  • Complaint filing portal
From our advocates: "We've seen several Washington patients successfully overturn Krystexxa denials through the IRO process. The key is thorough documentation of failed conventional therapies and clear evidence of medical necessity. Washington's external review system is particularly effective for rare disease medications where standard utilization management may not account for specialized treatment needs."

When to Contact the State

Consider escalating to Washington's Insurance Commissioner if:

  • UnitedHealthcare fails to respond within required timeframes
  • You believe the denial violates state insurance laws
  • The insurer requests inappropriate or excessive documentation
  • You experience delays that could impact your health

Update Schedule: When to Re-Check Resources

Healthcare coverage policies and forms change regularly. Stay current by checking these resources on this schedule:

Monthly Updates

  • Prior authorization forms (check for version updates)
  • Specialty pharmacy network (new locations, contract changes)
  • Member portal features (new tools, submission methods)

Quarterly Updates

  • Coverage policies for Krystexxa (criteria changes, new requirements)
  • Appeal procedures (timeline modifications, new rights)
  • Phone numbers and contacts (verify current numbers)

Annual Updates

  • Plan formularies (tier changes, new restrictions)
  • State regulations (Washington insurance law updates)
  • Provider networks (contract renewals, new partnerships)

Bookmark These Resources:

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules. For complex cases like Krystexxa approvals, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, consider consulting with healthcare advocacy services like Counterforce Health.

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