By Counterforce Health Team in Naglazyme (galsulfase) —

Resources to Get Naglazyme (galsulfase) Approved with UnitedHealthcare in New Jersey: Forms, Portals & Contacts

Quick Answer: Getting Naglazyme Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Naglazyme (galsulfase) through OptumRx. Submit requests via the UnitedHealthcare Provider Portal or fax to 1-844-403-1027. Required documentation includes confirmed MPS VI diagnosis via enzyme assay/genetic testing, baseline functional measures, and medical necessity letter. If denied, you have 180 days for internal appeals, followed by external review through New Jersey's Independent Health Care Appeals Program (IHCAP) managed by Maximus Federal Services.

First step today: Verify your plan type and gather diagnostic documentation, then submit the OptumRx Prior Authorization Request Form with complete clinical records.

Table of Contents

  1. Start Here: Verify Your Plan
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Fax and Mail Contacts
  5. Specialty Pharmacy Network
  6. Support Phone Lines
  7. New Jersey Appeals and Consumer Help
  8. When to Update Your Resources

Start Here: Verify Your Plan

Before submitting any forms, confirm your UnitedHealthcare plan type and pharmacy benefits manager:

  • Commercial Plans: Most use OptumRx for specialty drug management
  • Medicare Advantage: May have different prior authorization pathways
  • Medicaid/Community Plan: Follow state-specific requirements

Check your member ID card or log into myuhc.com to verify your pharmacy benefits. For New Jersey residents, UnitedHealthcare operates through their Network Management office at 1 Tower Center Boulevard, Suite 1100, East Brunswick, NJ 08816.

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all plan types OptumRx Prior Auth Guide
Formulary Tier Specialty tier (high cost-sharing) UHC Drug Lists
HCPCS Code J1458 UHC Admin Drug Chart
ICD-10 Code E76.29 (MPS VI) UHC ERT Policy
Appeals Deadline 180 days from denial NJ IHCAP Program

Required Forms and Documentation

Primary Form: OptumRx Prior Authorization Request

Submit the OptumRx Prior Authorization Request Form with these required elements:

Clinical Documentation Checklist:

  • ✅ Confirmed MPS VI diagnosis via enzyme assay or genetic testing results
  • ✅ Baseline functional measures (6-minute walk test, stair-climbing capacity)
  • ✅ Medical necessity letter addressing clinical rationale
  • ✅ Documentation of expected therapeutic goals
  • ✅ Patient weight for dosing calculations (1 mg/kg weekly)
  • ✅ Planned site of administration (hospital/infusion center)
Clinician Corner: Your medical necessity letter should reference FDA labeling for Naglazyme showing improved walking and stair-climbing capacity in MPS VI patients. Include baseline functional assessments and cite the lack of alternative enzyme replacement therapies for this specific mucopolysaccharidosis type.

Supporting Documentation

Laboratory/Diagnostic Requirements:

  • Enzyme assay results showing arylsulfatase B deficiency
  • Genetic testing confirming ARSB gene mutations (if available)
  • Urinary glycosaminoglycan levels
  • Baseline imaging (if relevant to patient presentation)

Prior Treatment Documentation:

  • No step therapy alternatives exist for MPS VI
  • Document any supportive care measures (orthopedic, cardiopulmonary)
  • Note contraindications to investigational therapies if applicable

Submission Portals and Methods

Online Portals

Primary Options:

  1. UnitedHealthcare Provider Portal: uhcprovider.com
    • Access prior authorization submission tools
    • Upload clinical documentation
    • Track request status
  2. CoverMyMeds Integration: OptumRx partners with CoverMyMeds for streamlined electronic prior authorization
    • Real-time status updates
    • Automated form population
    • Direct physician office integration
  3. Optum Pro Portal: optumproportal.com
    • Alternative submission pathway
    • Clinical documentation upload capability

Portal Access Requirements

  • Valid NPI and DEA numbers for prescribers
  • UnitedHealthcare provider enrollment
  • Secure login credentials
Tip: Set up portal access before you need it. Initial registration can take 24-48 hours for credential verification.

Fax and Mail Contacts

Prior Authorization Fax Numbers

Standard Requests:

  • Fax: 1-844-403-1027
  • Cover sheet: Include patient name, DOB, member ID, prescriber NPI, and "NAGLAZYME PRIOR AUTH REQUEST"

Urgent/Expedited Requests:

  • Phone: 1-800-711-4555
  • Criteria: Life-threatening conditions or significant functional decline

Mailing Address

For paper submissions (when electronic methods unavailable):

OptumRx Prior Authorization
P.O. Box 25183
Santa Ana, CA 92799-5183
Note: Fax submission typically processes faster than mail. Allow 5-7 business days for mailed requests versus 1-2 business days for fax.

Specialty Pharmacy Network

UnitedHealthcare's approved specialty pharmacy network for Naglazyme includes:

Network Providers

  • Accredo Health Group
  • AllianceRx Walgreens
  • FloMed Infusion Services
  • AleraCare
  • Amerita

Enrollment Process

  1. Prior Authorization Approval: Must be obtained before pharmacy enrollment
  2. Prescription Transfer: Physician submits prescription to chosen specialty pharmacy
  3. Patient Enrollment: Pharmacy contacts patient for intake and delivery coordination
  4. Infusion Setup: Coordinate home infusion nursing or infusion center administration

Home Infusion Considerations:

  • Naglazyme requires IV administration over several hours
  • Infusion-related reactions are common and require monitoring
  • Premedication protocols per FDA labeling

For additional support, Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and creating targeted, evidence-backed appeals that align with payer-specific criteria.

Support Phone Lines

Member Services

  • General Member Services: Number on your member ID card
  • Specialty Pharmacy Support: 1-855-427-4682 (24/7 availability)
  • OptumRx Prior Authorization: 1-800-711-4555

Provider Services

  • UnitedHealthcare Provider Services: 888-343-0059
  • Medical Benefit Management: 888-397-8129 (for provider-administered drugs)
  • Email: [email protected]
  • Hours: Monday-Friday, 7am-7pm Central Time

Case Management Support

For complex cases requiring additional coordination:

  • Request case management through your provider portal
  • Ask about peer-to-peer review opportunities
  • Inquire about expedited review criteria

What to Ask When Calling:

  1. Current status of your prior authorization request
  2. Specific documentation requirements for your plan
  3. Timeline for determination
  4. Appeal options if denied
  5. Specialty pharmacy enrollment process

New Jersey Appeals and Consumer Help

Internal Appeals Process

UnitedHealthcare Internal Appeals:

  • Deadline: 180 days from denial notice
  • Levels: Typically 2 internal review levels
  • Submission: Via provider portal, fax, or mail
  • Timeline: Standard review within 30 days; expedited within 72 hours

External Review: New Jersey IHCAP

After completing internal appeals, New Jersey residents can access external review through the Independent Health Care Appeals Program (IHCAP):

Key Details:

  • Administrator: Maximus Federal Services (contracted by NJ DOBI)
  • Deadline: 4 months (180 days) from final internal denial
  • Cost: Free to patients (insurers pay all fees)
  • Timeline: 5 business days for preliminary review; 45 days for full decision
  • Expedited: Available for urgent cases (much shorter timeframe)

IHCAP Contact Information:

  • Phone: 1-888-393-1062
  • General NJ DOBI Consumer Hotline: 1-800-446-7467

Consumer Assistance Resources

New Jersey Department of Banking and Insurance (DOBI):

  • Appeal and Complaint Guide available online
  • Consumer protection division assistance
  • Managed Care Ombudsman for additional support

Patient Advocacy Organizations:

  • National MPS Society
  • BioMarin RareConnections™ patient support program
  • New Jersey rare disease advocacy groups

When to Update Your Resources

Regular Update Schedule

Quarterly Reviews (Every 3 Months):

  • Check for formulary changes
  • Verify portal access and contact information
  • Review any policy updates

Annual Reviews:

  • Confirm specialty pharmacy network providers
  • Update emergency contact information
  • Review appeal rights and deadlines

Trigger Events for Immediate Updates

  • Plan changes (new employer, Medicare enrollment)
  • Denial letters citing new requirements
  • Changes in clinical status or dosing needs
  • Pharmacy network modifications
Important: UnitedHealthcare policies can change with 30-60 days notice. Always verify current requirements before submitting new requests.

From Our Advocates

We've seen cases where patients initially faced denials for Naglazyme due to incomplete functional assessments in their prior authorization. When families worked with their care teams to submit comprehensive 6-minute walk test results and detailed clinical progression notes, the appeals were successful. The key is demonstrating objective measures of disease progression and expected therapeutic benefit.

Counterforce Health specializes in transforming insurance denials into successful appeals by analyzing payer policies and creating evidence-based rebuttals. Our platform helps patients and clinicians navigate complex prior authorization requirements for specialty medications like Naglazyme, ensuring that clinical documentation aligns with UnitedHealthcare's specific coverage criteria and New Jersey's regulatory requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Coverage decisions depend on individual circumstances and specific plan benefits. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For additional consumer protection resources in New Jersey, contact the Department of Banking and Insurance at 1-800-446-7467.

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