By Counterforce Health Team in Taltz (ixekizumab) —

Taltz (ixekizumab) Approval with UnitedHealthcare in New York: Complete Guide with Forms, Appeals, and Patient Scripts

Quick Answer: Getting Taltz (ixekizumab) Covered by UnitedHealthcare in New York

Yes, UnitedHealthcare covers Taltz (ixekizumab) in New York, but requires prior authorization with documented step therapy failure. You must first try preferred biologics like Humira or Enbrel, plus complete TB screening. Fastest path: Have your dermatologist or rheumatologist submit a complete prior authorization through the OptumRx provider portal with all required documentation. Start today: Call UnitedHealthcare member services at the number on your card to confirm your plan's specific formulary status and step therapy requirements for Taltz.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Step Therapy Requirements
  5. Cost Information
  6. Denials and Appeals
  7. Renewal Process
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Patient Scripts and Templates

Coverage Basics

Is Taltz Covered by UnitedHealthcare?

Taltz is covered by most UnitedHealthcare plans in New York, but placement varies by plan type. Commercial and Marketplace plans typically place Taltz on specialty tier (Tier 4 or 5), while Medicare Advantage plans follow similar patterns. All plans require prior authorization with no exceptions.

Coverage varies by plan:

  • Commercial/Marketplace: Specialty tier with copays ranging $50-$500+ monthly
  • Medicare Advantage: Specialty tier with 25-33% coinsurance until you reach the $2,000 annual out-of-pocket maximum (2025)
  • Medicaid managed care: Coverage varies by specific plan
Note: Always verify your specific plan's formulary status by logging into your UnitedHealthcare member portal or calling the number on your insurance card.

Which Plans Cover Taltz?

Not all UnitedHealthcare plans include Taltz on their formulary. You must check your specific plan's Prescription Drug List before starting the prior authorization process. Plans that commonly cover Taltz include:

  • UnitedHealthcare Choice Plus
  • UnitedHealthcare Options PPO
  • UnitedHealthcare Navigate HMO
  • Most Medicare Advantage plans
  • Select Medicaid managed care plans

Prior Authorization Process

Who Submits the Prior Authorization?

Your prescribing physician (dermatologist or rheumatologist) must submit the prior authorization request. Patients cannot submit these requests directly. The process is managed through OptumRx, UnitedHealthcare's pharmacy benefit manager.

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient + Clinic)
    • Check formulary status on UnitedHealthcare member portal
    • Confirm step therapy requirements for your specific plan
    • Timeline: Same day
  2. Complete Clinical Documentation (Physician)
    • Document diagnosis with ICD-10 codes (L40.0 for psoriasis, M07.0-M07.3 for psoriatic arthritis)
    • Record disease severity (PASI scores, BSA involvement, joint counts)
    • Timeline: 1-2 visits
  3. Document Step Therapy (Physician)
    • Provide records of failed biologics (typically adalimumab, etanercept, or secukinumab)
    • Include drug names, dates, dosing, duration, and reasons for discontinuation
    • Timeline: Varies based on treatment history
  4. Complete TB Screening (Patient + Physician)
    • Order QuantiFERON-Gold or tuberculin skin test
    • Document negative results in clinical notes
    • Timeline: 1-3 days for results
  5. Submit Prior Authorization (Physician)
    • Use OptumRx provider portal for fastest processing
    • Include all clinical notes, step therapy records, and TB screening
    • Timeline: Same day submission
  6. Monitor Status (Patient + Clinic)
    • Track through provider portal or call OptumRx at 1-800-711-4555
    • Timeline: Up to 15 business days for standard review
  7. Receive Approval (Patient)
    • Prescription automatically routes to specialty pharmacy
    • Timeline: 2-3 days for first shipment

Timing and Urgency

How Long Does Prior Authorization Take?

Standard review: Up to 15 business days from submission of complete documentation
Expedited review: 72 hours for urgent medical situations
Incomplete submissions: Additional 5-10 days for information requests

What Qualifies for Urgent Review?

UnitedHealthcare approves expedited review when:

  • Delay would seriously jeopardize health
  • Patient is experiencing severe disease flare
  • Current treatment has failed and immediate alternative is needed

To request urgent review: Have your physician call OptumRx at 1-800-711-4555 and specify medical urgency with clinical justification.

Step Therapy Requirements

What Counts as Step Therapy for Taltz?

You must document trial and failure of at least one preferred biologic before Taltz approval. UnitedHealthcare's typical step therapy sequence includes:

Tier 1 Preferred Biologics:

  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Secukinumab (Cosentyx)

Required Documentation:

  • Drug name and NDC number
  • Start and end dates
  • Dosing and frequency
  • Duration of trial (typically 3+ months)
  • Specific reason for discontinuation (inadequate response, adverse effects, contraindication)

Exceptions to Step Therapy

Step therapy may be waived if you have:

  • Medical contraindication to preferred agents
  • History of serious adverse reaction to required medications
  • Drug-drug interactions with current medications
  • Previous trial and failure on another insurance plan (requires documentation)

Cost Information

Copay vs. Coinsurance: What to Expect

Commercial/Marketplace Plans:

  • Specialty tier copay: $50-$500+ per month (varies by plan)
  • Deductible: May apply before copay kicks in
  • Annual out-of-pocket maximum: Varies by plan ($2,000-$8,000+)

Medicare Advantage:

  • Coinsurance: 25-33% of drug cost until $2,000 annual maximum
  • After $2,000: Plan pays 100% for rest of year (2025 benefit)

Savings Options

Manufacturer Support:

  • Taltz Savings Card reduces copay to $5/month for commercially insured patients
  • Income limits and other restrictions apply

Foundation Support:

  • Lilly Cares Foundation for uninsured patients
  • Various copay assistance foundations for Medicare patients

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing step therapy Document prior biologic trials Pharmacy records, clinical notes with dates/outcomes
Outdated TB screening Submit recent negative test QuantiFERON-Gold or TST results within policy timeframe
Insufficient diagnosis documentation Provide detailed clinical assessment PASI scores, photos, joint counts, functional impact
Non-formulary status Request formulary exception Medical necessity letter with clinical justification

Appeals Process in New York

Internal Appeal (Required First Step):

  • Timeline: 180 days from denial date to file
  • Review time: 30 days for standard, 72 hours for urgent
  • How to file: UnitedHealthcare member portal or mail to address on denial letter

External Review (After Internal Denial):

Patient Script for Appeal Calls

"Hi, I'm calling to file an internal appeal for a denied prior authorization. My member ID is [ID number]. The drug is Taltz, generic name ixekizumab, and it was denied on [date]. I have additional clinical documentation that shows medical necessity. Can you help me submit this appeal and confirm the deadline?"

Renewal Process

When to Re-authorize Taltz

Most approvals are valid for 12 months. You'll need to renew if:

  • Your approval is expiring (check approval letter for exact date)
  • You're switching UnitedHealthcare plans
  • Your physician wants to change dosing

What Documentation is Needed for Renewal

Clinical Response Documentation:

  • Current disease activity scores (PASI, joint counts)
  • Physician assessment of treatment response
  • Any adverse effects or tolerability issues
  • Continued medical necessity statement

The renewal process is typically faster than initial approval since step therapy requirements are already satisfied.

Specialty Pharmacy Requirements

Why Was My Prescription Transferred?

Taltz must be dispensed through an in-network specialty pharmacy. UnitedHealthcare typically uses:

  • Optum Specialty Pharmacy (most common)
  • Walgreens Specialty Pharmacy
  • Accredo Specialty Pharmacy

What to Expect from Specialty Pharmacy

  • Free home delivery with temperature-controlled packaging
  • 24/7 pharmacist support at 1-855-427-4682
  • Automatic refill coordination with your physician
  • Patient education and injection training resources

Track your order: Use the Optum Specialty Pharmacy patient portal or UnitedHealthcare app.

Troubleshooting Common Issues

Portal Problems

Provider portal down: Call OptumRx at 1-800-711-4555 for phone submission
Missing forms: Download current PA forms from UnitedHealthcare provider resources
Status not updating: Allow 24-48 hours after submission for system updates

Documentation Issues

Missing prior therapy records: Contact previous physicians' offices directly
TB test expired: Most plans require testing within 6-12 months of starting Taltz
Incomplete clinical notes: Ask your physician to document specific severity measures

Patient Scripts and Templates

Calling UnitedHealthcare Member Services

"I need to check my plan's coverage for Taltz, spelled T-A-L-T-Z, generic name ixekizumab. Can you tell me if it's on my formulary, what tier it's on, and what the step therapy requirements are? My member ID is [number]."

Requesting Clinical Records

Email template for previous physicians:

Subject: Medical Records Request for Insurance Appeal

Dear [Physician's Office],

I need documentation of my previous treatment with [drug name] from [dates] for an insurance prior authorization. Please provide records showing the drug name, dosing, duration, and reason for discontinuation. My date of birth is [DOB] and previous patient ID was [if known].

Thank you,
[Your name and contact information]

Frequently Asked Questions

How long does UnitedHealthcare PA take in New York?
Up to 15 business days for standard review, 72 hours for expedited urgent cases.

What if Taltz is not on my formulary?
Request a formulary exception with a detailed medical necessity letter from your physician.

Can I request an expedited appeal?
Yes, if delay would seriously jeopardize your health. Your physician must provide clinical justification.

Does step therapy apply if I failed medications on a different insurance?
Usually yes, but you can provide documentation of previous failures to potentially satisfy requirements.

What's the difference between internal and external appeals in New York?
Internal appeals are with UnitedHealthcare directly. External appeals are with New York DFS and provide independent medical review.

Can I use manufacturer copay cards with UnitedHealthcare?
Yes, if you have commercial coverage. Medicare patients are not eligible for manufacturer copay assistance.

From our advocates: We've seen patients successfully appeal Taltz denials by focusing on the step therapy documentation. One key tip: make sure your physician includes specific dates, dosing, and clinical outcomes for each prior biologic trial. Vague statements like "patient failed Humira" aren't sufficient – you need "patient tried adalimumab 40mg every other week from 1/15/24 to 4/30/24 with inadequate PASI response (baseline PASI 18, post-treatment PASI 14)." This level of detail significantly improves approval odds.

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, making the appeals process more efficient for everyone involved.

If you're facing repeated denials or need help with the appeals process, Counterforce Health can analyze your denial letter and create a customized appeal strategy based on your plan's specific requirements and New York's regulatory framework.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may change. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For assistance with insurance denials and appeals in New York, contact Community Health Advocates at 888-614-5400.

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