By Counterforce Health Team in Xenpozyme (olipudase alfa-rpcp) —

Resources to Get Xenpozyme (olipudase alfa-rpcp) Approved with UnitedHealthcare in Michigan: Forms, Portals & Contacts

Quick Start: Getting Xenpozyme Covered by UnitedHealthcare in Michigan

Xenpozyme (olipudase alfa-rpcp) requires prior authorization from UnitedHealthcare/OptumRx for coverage approval. Your fastest path: verify your Michigan plan's specialty drug benefits, gather ASMD diagnosis documentation, and submit the PA request through the UnitedHealthcare Provider Portal or OptumRx electronic system. If denied, you have 180 days for internal appeals, followed by Michigan DIFS external review within 127 days. Start today by confirming your plan details and collecting genetic test results or enzyme assays proving acid sphingomyelinase deficiency.

Table of Contents

  1. Verify Your Plan & Find the Correct Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Options
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Network
  6. Support Lines & Contact Numbers
  7. Michigan Appeals & External Review
  8. When to Update Your Resources

1. Verify Your Plan & Find the Correct Forms

Before submitting any paperwork, confirm your specific UnitedHealthcare plan type in Michigan. The forms and procedures vary between:

  • Commercial/Employer plans (managed by OptumRx)
  • Medicare Advantage plans
  • UnitedHealthcare Community Plan (Medicaid/CHIP)
Tip: Check your member ID card for plan details, or log into your member portal to verify coverage specifics.

Your denial letter or benefits summary will specify which forms to use and where to submit them. For Xenpozyme specifically, expect prior authorization requirements regardless of your plan type due to the medication's specialty status and high cost (approximately $1,515-$7,576 per vial depending on strength).

2. Prior Authorization Forms & Requirements

Standard PA Documentation

For all UnitedHealthcare plans in Michigan, you'll typically need:

  • OptumRx Prior Authorization Request Form (for specialty drugs)
  • Clinical documentation of confirmed ASMD diagnosis
  • Genetic testing or enzyme assay results
  • Baseline organ function measurements (spleen size, lung function, platelet count)
  • Prescriber attestation of medical necessity

Key Approval Criteria

Based on current UnitedHealthcare policies, Xenpozyme approval typically requires:

Requirement Documentation Needed Where to Find
ASMD diagnosis Genetic test or enzyme assay Lab reports, genetic counselor notes
Specialist oversight Prescription from/consultation with metabolic specialist Referral documentation
Baseline measurements Spleen size, lung function, CBC Imaging reports, pulmonary function tests
Monitoring plan Regular follow-up schedule Provider treatment plan
Note: For reauthorization, you'll need evidence of clinical improvement in key endpoints like organ size reduction or improved platelet counts.

3. Submission Portals & Electronic Options

UnitedHealthcare Provider Portal

Primary submission method for providers:

  • Access at UHCprovider.com
  • Requires One Healthcare ID with multifactor authentication (as of March 2025)
  • Select "Prior Authorization and Notification" tool
  • Upload medical records and attachments directly

Account Requirements:

  • Direct phone line (no extensions) for authentication
  • Recovery codes for account access
  • Support available at 855-819-5909

OptumRx Electronic Prior Authorization

For specialty medications like Xenpozyme:

  • OptumRx ePA portal
  • Streamlined submissions with faster turnaround
  • Real-time status updates
  • Integration with provider EHR systems
Important: Xenpozyme is not currently eligible for OptumRx's automated PreCheck Prior Authorization program, so expect manual review.

4. Fax Numbers & Mailing Addresses

Critical: Use Your Denial Letter First

Always refer to your specific denial letter for exact contact information. Fax numbers and addresses can vary by plan type and region.

General UnitedHealthcare Contacts

If denial letter details are unclear:

  • Customer Service: (877) 842-3210
  • Provider Advocate line for submission guidance

Cover Sheet Tips:

  • Include patient name and member ID
  • Mark "URGENT" if time-sensitive
  • List total pages being faxed
  • Include return fax number for confirmations
Warning: Never use outdated contact information. UnitedHealthcare frequently updates submission addresses and fax numbers.

5. Specialty Pharmacy Network

In-Network Specialty Pharmacies for Michigan

Primary Options:

  • Optum Specialty Pharmacy (UnitedHealthcare's preferred network)
  • Option Care Health (widely contracted)

Both pharmacies provide:

  • Prior authorization coordination
  • Home delivery or infusion site shipping
  • Clinical nursing support
  • Patient education and monitoring

Onboarding Process

  1. Provider initiates prescription with specialty pharmacy
  2. Pharmacy verifies insurance benefits and PA status
  3. Clinical team coordinates first shipment and infusion scheduling
  4. Ongoing support includes refill management and adverse event monitoring

Direct Contacts:

  • Optum Specialty Pharmacy Provider Support: 1-877-342-9352
  • Option Care Health Client Services: (verify current number with your plan)

6. Support Lines & Contact Numbers

Member Support

UnitedHealthcare Customer Service: (877) 842-3210

  • Benefit verification
  • PA status checks
  • Appeal guidance
  • Formulary questions

Provider Support

What to ask when calling:

  • Current PA requirements for Xenpozyme
  • Required clinical documentation
  • Expected review timeline
  • Appeal procedures if denied

Case Management

For complex cases involving Xenpozyme, request assignment to a case manager who can:

  • Coordinate between clinical teams and coverage reviewers
  • Expedite urgent requests
  • Provide ongoing coverage support

7. Michigan Appeals & External Review

Internal UnitedHealthcare Appeals

Timeline: 180 days from denial date Submission: Use method specified in denial letter Documentation: Include all supporting clinical evidence

Michigan DIFS External Review

If UnitedHealthcare's internal appeal is unsuccessful:

Contact Information:

  • Phone: 877-999-6442 (Monday-Friday, 8 AM - 5 PM)
  • Email: [email protected]
  • Fax: 517-284-8838
  • Mail: DIFS Office of Appeals, P.O. Box 30220, Lansing, MI 48909-7720

Required Forms:

Timeline: 127 days from final UnitedHealthcare denial Expedited Review: 72 hours for urgent cases (requires physician certification)

Appeals Playbook

Level Deadline Where to Submit Required Forms
Internal UHC 180 days Portal/fax per denial letter Appeal form + clinical docs
External DIFS 127 days DIFS online portal FIS 0018 + supporting evidence
Judicial 60 days Michigan courts Legal counsel recommended

8. When to Update Your Resources

Review these resources every 3 months:

  • UnitedHealthcare formulary updates
  • OptumRx PA requirements
  • Michigan DIFS contact information
  • Specialty pharmacy network changes

Annual Reviews:

  • Plan benefit changes (usually January)
  • State insurance regulation updates
  • New FDA labeling or clinical guidelines
Bookmark: Save links to official portals and forms, but always verify current versions before submitting.

FAQ: Common Questions About Xenpozyme Coverage

How long does UnitedHealthcare PA take in Michigan? Standard review is typically 5-15 business days. Urgent requests may qualify for 72-hour expedited review if clinical urgency is documented.

What if Xenpozyme is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Emphasize that no FDA-approved alternatives exist for ASMD.

Can I request an expedited appeal? Yes, if delay would jeopardize your health. Your physician must provide written certification of medical urgency.

Does step therapy apply to Xenpozyme? Unlikely, given no FDA-approved alternatives for ASMD exist. However, insurers may require documentation of supportive care attempts.

What counts as sufficient ASMD diagnosis documentation? Genetic testing showing SMPD1 mutations or enzyme assay confirming acid sphingomyelinase deficiency, plus clinical evidence of non-CNS manifestations.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right clinical evidence and regulatory citations to support coverage requests for complex medications like Xenpozyme.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult your healthcare provider and insurance plan directly for personalized guidance. For additional support with Michigan insurance appeals, contact Counterforce Health or the Michigan Department of Insurance and Financial Services at 877-999-6442.

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