By Counterforce Health Team in Upstaza (eladocagene exuparvovec) —

Resources to Get Upstaza (Kebilidi) Approved with UnitedHealthcare in Texas: Forms, Portals & Contacts

Answer Box: Getting Upstaza Covered by UnitedHealthcare in Texas

Upstaza (eladocagene exuparvovec), now marketed as Kebilidi™ in the US, requires prior authorization from UnitedHealthcare OptumRx for AADC deficiency. Submit requests via the UnitedHealthcare Provider Portal with genetic testing, clinical documentation, and medical necessity letter. If denied, Texas law provides strong appeal rights through internal review (180 days) and external Independent Review Organization (IRO) through Texas Department of Insurance. Start by verifying your plan type and gathering genetic test results showing biallelic DDC mutations.

Table of Contents

Start Here: Verify Your Plan

Before submitting any prior authorization request, confirm your UnitedHealthcare plan details:

Check Your Insurance Card for:

  • Plan type (Commercial, Medicare Advantage, STAR Medicaid)
  • Pharmacy benefits manager (OptumRx handles most UHC plans)
  • Member ID and group number
  • Customer service phone number

Verify Coverage Online:

  1. Log into myuhc.com (members) or UHCprovider.com (providers)
  2. Check if Kebilidi requires prior authorization under your specific plan
  3. Download your current formulary and benefit summary
Note: Self-funded employer plans (ERISA) follow federal appeal rules, not Texas state regulations. Fully-insured Texas plans are subject to Texas Department of Insurance oversight.

Required Forms and Documentation

Prior Authorization Request

Primary Submission Method: Electronic via UnitedHealthcare Provider Portal

Required Clinical Documentation:

  • Genetic testing showing biallelic DDC gene mutations
  • Plasma AADC enzyme activity results
  • Anti-AAV2 antibody titer (≤1:1200 per UHC policy)
  • Detailed clinical notes documenting non-ambulatory status
  • Prior treatment history with dopaminergic agents
  • Medical necessity letter from neurologist

UnitedHealthcare Kebilidi Coverage Criteria

According to UHC's Kebilidi policy, approval requires:

Requirement Documentation Needed
Confirmed AADC deficiency Biallelic pathogenic DDC mutations
Severe phenotype Unable to ambulate independently
Age eligibility 1 to <18 years (clinical trial population)
No prior gene therapy Lifetime treatment limitation
Qualified facility Certified neurosurgical/gene therapy center
Prescriber qualification Neurologist or neurosurgeon with AADC experience

Medical Necessity Letter Template

Your neurologist should address these points:

  • Confirmed genetic diagnosis with lab report reference
  • Clinical severity (oculogyric crises, dystonia, developmental delay)
  • Failed or inadequate response to standard therapies
  • No alternative disease-modifying treatments available
  • Request for step-therapy exception if applicable

Submission Portals and Electronic Access

UnitedHealthcare Provider Portal

  • URL: UHCprovider.com
  • Access: Prior Authorization and Notification dashboard
  • Upload capability: Clinical notes, lab results, imaging
  • Status tracking: Real-time PA request monitoring

Electronic Prior Authorization (ePA)

  • Supported through Surescripts integration
  • OptumRx PreCheck: Automated approvals for eligible drugs (expanding to 45+ medications by 2026)
  • EHR integration available for participating health systems

Provider Portal Login Steps:

  1. Navigate to UHCprovider.com
  2. Sign in with One Healthcare ID
  3. Select "Prior Authorization and Notification"
  4. Search drug name: "Kebilidi" or "eladocagene exuparvovec"
  5. Complete required fields and upload documentation
Tip: Submit all clinical documentation at initial request to avoid delays and "lack of information" denials.

Fax Numbers and Mailing Addresses

Important: Fax numbers vary by plan type and are not universal across all UnitedHealthcare products.

How to Find Correct Fax Numbers:

  • OptumRx PA Line: 1-800-711-4555 (request plan-specific fax number)
  • Check your denial letter for case-specific fax information
  • Use fax number provided on OptumRx PA forms for your plan type

Texas STAR Medicaid Plans:

Warning: Do not use generic internet-listed fax numbers. Always verify the current number for your specific plan through OptumRx customer service.

Specialty Pharmacy Onboarding

Optum Specialty Pharmacy Process

Contact Information:

  • Phone: 1-855-427-4682 (24/7)
  • Handles complex biologics and gene therapies
  • Manages cold-chain shipping and infusion coordination

Onboarding Steps:

  1. Provider initiates prescription transfer
  2. Optum verifies benefits and handles PA if needed
  3. Coordinates specialized shipping (-60°C to -80°C storage)
  4. Schedules infusion with certified facility
  5. Provides patient education and support services

Transfer Instructions:

  • Provide complete prescription details to Optum
  • Verify coverage and prior authorization status
  • Coordinate with infusion center for single-dose administration
  • Monitor for limited shelf-life post-manufacture

Patient Services Include:

  • Virtual consultations
  • Financial assistance navigation
  • Adherence support and monitoring
  • Refill coordination (phone-based for gene therapies)

Support Phone Lines and Contacts

Member Services

  • UnitedHealthcare Customer Service: Number on back of insurance card
  • OptumRx Pharmacy: 1-800-711-4555
  • Specialty Pharmacy: 1-855-427-4682

Provider Services

  • Provider Services: 1-888-397-8129 (oncology/specialty drugs)
  • Prior Authorization Support: Available through provider portal chat
  • Case Management: For complex specialty drug cases

What to Ask When Calling:

  • Confirm PA requirements for Kebilidi/eladocagene exuparvovec
  • Request current coverage policy and criteria
  • Verify submission deadlines and required documentation
  • Ask about expedited review options for urgent cases

Texas Regulator and Consumer Assistance

Texas Department of Insurance (TDI)

Consumer Help Line: 1-800-252-3439

  • Assistance with insurance appeals and external reviews
  • Verification of plan regulation status (state vs. federal)
  • Complaint filing for non-compliance

External Review (IRO) Process:

  • Available for medical necessity denials
  • Must complete internal appeal first (except urgent cases)
  • Use TDI Form LHL009 for IRO requests
  • Submit to insurer, not directly to TDI

Office of Public Insurance Counsel (OPIC):

  • Help Line: 1-877-611-6742
  • Detailed guidance on appealing denied claims
  • Consumer advocacy and education

Additional Texas Resources

  • Disability Rights Texas: Assistance with Medicaid appeals and fair hearings
  • IRO Information Line: 1-866-554-4926
  • TDI Consumer Complaint Portal: Available online at tdi.texas.gov

Appeals Process in Texas

Internal Appeals with UnitedHealthcare

  • Timeline: 180 days from denial to file appeal
  • Decision timeframe: 30 days for pre-service, 60 days for post-service
  • Expedited appeals: Available for urgent medical situations
  • Required: Must be completed before external review

External Review (IRO)

  • Eligibility: Medical necessity, experimental/investigational denials
  • Timeline: Must request within 4 months of final internal denial
  • Process: UHC forwards request to TDI within 1 working day
  • Decision: Standard reviews decided within timeframes set by Texas rules; urgent reviews much faster
  • Binding: IRO decision is binding on UnitedHealthcare

IRO Request Steps:

  1. Complete TDI Form LHL009
  2. Attach all denial letters and medical records
  3. Submit to UnitedHealthcare (not TDI)
  4. Track to ensure UHC forwards to TDI within 1 working day
  5. Respond promptly to IRO requests for additional information
From our advocates: We've seen successful IRO appeals for gene therapies when families included comprehensive genetic testing results, detailed treatment history showing failed alternatives, and letters from multiple specialists confirming the lack of other disease-modifying options. Complete documentation upfront significantly improves outcomes.

When to Update These Resources

Check for Updates:

  • Quarterly: UnitedHealthcare policy updates and formulary changes
  • Annually: Texas insurance regulations and TDI contact information
  • As needed: When receiving denial letters with new contact information

Key Update Triggers:

  • New FDA approvals or label changes for Kebilidi
  • UnitedHealthcare merger or acquisition activity
  • Texas legislative changes affecting insurance appeals
  • OptumRx system updates or portal changes

Where to Monitor:

FAQ

How long does UnitedHealthcare PA take for Kebilidi in Texas? Standard prior authorization decisions are typically made within 15 business days. Expedited reviews for urgent cases may be decided within 72 hours.

What if Kebilidi is non-formulary on my plan? Non-formulary drugs can still be covered through medical exception or appeal. Submit strong medical necessity documentation and request formulary exception.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health or ability to regain function. Provide physician documentation supporting urgency.

Does step therapy apply if I've failed treatments outside Texas? Treatment history from other states should be accepted. Include complete documentation of prior therapies, doses, durations, and outcomes.

What's the difference between OptumRx and UnitedHealthcare? OptumRx is UnitedHealthcare's pharmacy benefit manager. Both are part of UnitedHealth Group and handle different aspects of coverage.

How much does Kebilidi cost without insurance? Gene therapies typically cost millions of dollars. Manufacturer patient assistance programs and foundation grants may be available for eligible patients.

Can I appeal to both TDI and federal agencies? Appeal rights depend on your plan type. Fully-insured Texas plans use TDI IRO process. Self-funded ERISA plans follow federal external review procedures.

What happens if UnitedHealthcare doesn't follow the IRO decision? IRO decisions are binding. Contact TDI consumer services to report non-compliance and request enforcement action.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes for high-cost specialty medications. Our platform analyzes denial letters and plan policies to create targeted, evidence-based appeals that significantly improve approval rates for treatments like Kebilidi. By understanding each payer's specific requirements and combining them with the right clinical evidence, we help turn insurance denials into successful outcomes for patients who need life-changing therapies.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage determinations. For assistance with Texas insurance appeals, contact the Texas Department of Insurance consumer help line at 1-800-252-3439.

Sources & Further Reading

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