By Counterforce Health Team in Turalio (pexidartinib) —

Resources to Get Turalio (Pexidartinib) Approved with UnitedHealthcare in Illinois: Forms, Portals & Contact Guide

Answer Box: Getting Turalio (Pexidartinib) Covered by UnitedHealthcare in Illinois

Fastest path to approval: Complete UnitedHealthcare's prior authorization form with TGCT diagnosis documentation, surgical consultation notes, and REMS enrollment proof. Submit via the UnitedHealthcare Provider Portal or fax to OptumRx. First step today: Verify your plan requires PA by calling the number on your insurance card, then gather baseline liver function tests and imaging confirming TGCT diagnosis. If denied, Illinois allows external review within 4 months through the Illinois Department of Insurance.

Table of Contents

Start Here: Verify Your Plan

Before gathering documents, confirm your UnitedHealthcare plan requires prior authorization for Turalio. Call the customer service number on your insurance card and ask:

  • Does my plan require PA for Turalio (pexidartinib)?
  • What's my formulary tier for this medication?
  • Are there step therapy requirements?
  • Which specialty pharmacy should I use?

Most UnitedHealthcare plans administered through OptumRx require prior authorization for Turalio, with authorizations typically issued for 12 months upon meeting coverage criteria.

Note: Patients under 19 years may qualify for automatic processing without detailed coverage review.

Required Forms

Primary Prior Authorization Form

  • Form: UnitedHealthcare Turalio Prior Authorization Notification
  • Current as of: 2024
  • Required documentation:
    • TGCT diagnosis with ICD-10 code M12.2
    • Imaging confirming tenosynovial giant cell tumor
    • Surgical consultation notes explaining why surgery isn't viable
    • Baseline liver function tests
    • REMS enrollment confirmation

Step Therapy Exception Form

If your plan requires trying other medications first, use the Step Therapy Protocol Exception Form. Document:

  • Previous medications tried (names, doses, duration)
  • Reasons for discontinuation or contraindications
  • Clinical rationale for Turalio as first-line therapy

REMS Program Forms

Turalio requires FDA REMS program enrollment for both prescriber and patient:

  • Prescriber Enrollment Form and Knowledge Assessment
  • Patient Enrollment Form (completed with prescriber)
  • Baseline liver function test results

Submission Portals

UnitedHealthcare Provider Portal

  • URL: UHCprovider.com
  • Access: Requires One Healthcare ID registration
  • Features:
    • Submit PA requests through "Prior Authorization and Notification" tool
    • Upload medical records, lab results, and imaging directly
    • Track status with TrackIt feature
    • Receive notifications when additional documentation is needed
Tip: Color photographs must be uploaded via the portal; faxed color images aren't accepted.

OptumRx Portal

For pharmacy benefit management:

  • Phone: 1-800-711-4555
  • Online: Through UnitedHealthcare provider portal
  • Timeline: Standard review 7-30 days; expedited within 72 hours

Fax & Mail Options

Primary Submission

  • Fax: Use the fax number provided on your specific PA form (varies by region)
  • Cover sheet tip: Include patient name, DOB, member ID, and "TURALIO PRIOR AUTHORIZATION" in large text

Appeals & Additional Documentation

  • General provider fax: Check your denial letter for specific fax numbers
  • Mail: Address provided in denial correspondence
  • Required: Always include member ID and reference numbers

Specialty Pharmacy Network

Turalio can only be dispensed through REMS-certified specialty pharmacies. UnitedHealthcare's network includes certified pharmacies that can:

Enrollment Steps

  1. Verify pharmacy is REMS-certified
  2. Transfer prescription from regular pharmacy if needed
  3. Confirm patient REMS enrollment before first fill
  4. Coordinate ongoing liver function monitoring

Dispensing Restrictions

  • Maximum 30-day supply for first 3 months
  • Cannot dispense without confirmed REMS compliance
  • Requires liver function test results for refills

Support Lines

For Patients

  • UnitedHealthcare Customer Service: Number on your insurance card
  • REMS Program Support: 1-833-TURALIO (1-833-887-2546)
  • OptumRx: 1-800-711-4555

For Providers

  • Prior Authorization: Use provider portal or call number on PA form
  • Peer-to-peer review: Request through customer service
  • Clinical support: REMS program at 1-833-887-2546

What to Ask

When calling support:

  • "What specific documentation is missing from my PA request?"
  • "Can I request expedited review due to medical urgency?"
  • "What's the status of my prior authorization?"
  • "How do I request a peer-to-peer review?"

Illinois Regulator & Consumer Assistance

Illinois Department of Insurance

Consumer Rights in Illinois

Illinois provides strong appeal protections under the Health Carrier External Review Act:

  • Independent physician review of denials
  • No cost to consumers for external review
  • Expedited review for urgent cases (24-72 hours)
  • Binding decisions that insurers must follow

Additional Help

  • Illinois Attorney General Health Care Helpline: 1-877-305-5145
  • Office of Consumer Health Insurance: 877-527-9431

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with your insurer's specific requirements, helping patients and providers navigate complex prior authorization processes more effectively.

Update Schedule

How Often to Check Resources

  • Forms: Quarterly (January, April, July, October)
  • Portal access: Verify login credentials monthly
  • Contact numbers: Check denial letters for most current information
  • State regulations: Annual review of Illinois Department of Insurance updates

Where to Find Updates

Common Denial Reasons & Solutions

Denial Reason Required Documentation Where to Submit
Missing TGCT diagnosis Pathology report, imaging with radiologist interpretation Provider portal or PA form
Surgery not addressed Orthopedic/surgical consultation notes stating inoperability Upload to portal with PA
REMS not enrolled Completed prescriber and patient enrollment forms REMS program: 1-833-887-2546
Insufficient liver monitoring Baseline ALT, AST, bilirubin results Attach to PA submission
Step therapy required Documentation of contraindications to alternatives Step therapy exception form

Appeals Process

Internal Appeals (UnitedHealthcare)

  1. Timeline: File within 180 days of denial
  2. Method: Provider portal, phone, or written request
  3. Documentation: Include all supporting medical records
  4. Decision: Typically 15 business days (24 hours if expedited)

External Review (Illinois)

  1. Eligibility: After internal appeal denial for medical necessity
  2. Timeline: Request within 4 months of final denial
  3. Form: Illinois External Review Form
  4. Review: Independent physician assessment within 5 business days
Important: Illinois has a shorter external review deadline (4 months) compared to many states, so act promptly after appeal denials.

Expedited Appeals

For urgent cases where delays could jeopardize health:

  • Request through customer service
  • Provide physician certification of urgency
  • Decisions typically within 24-72 hours

FAQ

How long does UnitedHealthcare PA take for Turalio in Illinois? Standard review: 7-30 days. Expedited review: within 72 hours for urgent cases.

What if Turalio is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate.

Can I get Turalio covered if I haven't tried other treatments? Yes, if you have contraindications to alternatives or if TGCT severity requires immediate treatment. Document medical rationale thoroughly.

Does REMS enrollment delay coverage approval? REMS enrollment is required before dispensing but can be completed in parallel with PA submission to minimize delays.

What happens if my appeal is denied in Illinois? You can request external review through the Illinois Department of Insurance within 4 months of the final denial.

Sources & Further Reading

Disclaimer: This information is for educational purposes and doesn't constitute medical advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult your healthcare provider and insurance plan documents for specific guidance. For personalized assistance with complex appeals, Counterforce Health provides specialized support for turning denials into successful approvals.

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