By Counterforce Health Team in Tavneos (avacopan) —

The Requirements Checklist to Get Tavneos (avacopan) Covered by UnitedHealthcare in Washington: Complete Prior Authorization Guide

Answer Box: Getting Tavneos Covered by UnitedHealthcare in Washington

Who qualifies: Patients 18+ with severe active ANCA-associated vasculitis (GPA or MPA) prescribed by a specialist (rheumatologist, nephrologist, pulmonologist) using Tavneos as adjunctive therapy with standard immunosuppressants.

Fastest approval path:

  1. Complete UnitedHealthcare's prior authorization form with specialist documentation
  2. Submit through OptumRx specialty pharmacy network
  3. If denied, request peer-to-peer review within one business day

Washington advantage: Strong external review rights through Independent Review Organizations (IROs) with 30-52% overturn rates for medical necessity denials.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Hygiene
  5. Documentation Packet Essentials
  6. Submission Mechanics
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking Your Request
  9. Denial Prevention Tips
  10. Washington State Appeals Process
  11. Printable One-Page Checklist
  12. FAQ

Who Should Use This Checklist

This guide is designed for patients with ANCA-associated vasculitis and their healthcare teams navigating UnitedHealthcare's prior authorization requirements for Tavneos (avacopan) in Washington state.

Use this checklist if you:

  • Have been diagnosed with severe active granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)
  • Are 18 years or older
  • Have UnitedHealthcare commercial insurance or Medicare Advantage
  • Need Tavneos as part of combination therapy (not as monotherapy)
  • Are working with a specialist prescriber

Expected outcome: Following this checklist increases your likelihood of first-time approval and provides clear next steps if initially denied. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Tavneos, helping patients navigate these exact scenarios with payer-specific workflows.

Member & Plan Basics

Coverage Verification Checklist

✅ Active UnitedHealthcare coverage confirmed through member portal
✅ Pharmacy benefits include specialty drug coverage
✅ Deductible status checked (specialty drugs may have separate deductibles)
✅ Prior authorization requirement confirmed (required for all Tavneos prescriptions)

Plan Type Considerations

Plan Type Key Requirements Special Notes
Commercial PPO/HMO Standard PA required Most common pathway
Medicare Advantage PA + step therapy likely May have different appeal timelines
Self-funded employer Varies by plan May follow different external review rules
Note: UnitedHealthcare requires prior authorization for Tavneos effective April 1, 2025, across all commercial plans.

Clinical Criteria Requirements

Diagnosis Requirements

Must have documented:

  • Severe active ANCA-associated vasculitis (GPA or MPA)
  • Positive serum assay for anti-proteinase-3 (anti-PR3) OR anti-myeloperoxidase (anti-MPO) antibodies
  • Clinical evidence of active disease affecting major organs

Combination Therapy Mandate

✅ Standard immunosuppressive therapy must be prescribed concurrently:

  • Glucocorticoids (required)
  • PLUS one or more: rituximab, cyclophosphamide, methotrexate, azathioprine, or mycophenolate
Critical: Tavneos monotherapy is never approved. UnitedHealthcare's policy explicitly requires adjunctive use.

Prescriber Requirements

✅ Specialist prescriber required:

  • Rheumatologist
  • Nephrologist
  • Pulmonologist
  • Vascular medicine specialist

Step Therapy Considerations

Most UnitedHealthcare plans require documentation of:

  • Previous treatment with standard vasculitis therapies
  • Evidence of inadequate response, intolerance, or contraindications to first-line treatments

Coding and Billing Hygiene

ICD-10 Codes for ANCA-Associated Vasculitis

Condition Primary ICD-10 Additional Codes
Granulomatosis with polyangiitis M31.30 (unspecified) M31.31 (with renal involvement)
Microscopic polyangiitis M31.7 Add organ-specific codes as appropriate

NDC and Billing Information

  • NDC: Tavneos 10mg capsules (verify current NDC with OptumRx)
  • Quantity limit: 180 capsules per 30 days (standard dosing: 30mg BID = 6 caps/day)
  • Billing: Pharmacy benefit (not J-code/medical benefit)

Documentation Packet Essentials

Provider Note Requirements

Your specialist's documentation must include:

✅ Diagnosis confirmation

  • ANCA test results (anti-PR3 or anti-MPO positive)
  • Clinical manifestations of active disease
  • Organ involvement assessment

✅ Prior treatment history

  • Previous therapies tried
  • Reasons for discontinuation or inadequate response
  • Contraindications to alternatives

✅ Current treatment plan

  • Concurrent immunosuppressive medications
  • Tavneos dosing rationale (30mg BID with food)
  • Monitoring plan for liver function

Medical Necessity Letter Components

  1. Patient identification and diagnosis
  2. Clinical rationale for Tavneos specifically
  3. Prior treatment failures or contraindications
  4. Supporting evidence from FDA labeling and clinical guidelines
  5. Monitoring plan and safety considerations

Required Attachments

✅ Laboratory results (ANCA, CBC, comprehensive metabolic panel, liver function tests)
✅ Imaging studies (if applicable)
✅ Previous treatment records
✅ Specialist consultation notes

Submission Mechanics

UnitedHealthcare Prior Authorization Form

Current form: PA Medical Necessity - Tavneos (PDF)

Submission options:

  1. UnitedHealthcare Provider Portal (fastest)
  2. Fax: (verify current fax number through provider portal)
  3. Mail: (check current address in PA form)

Common Rejection Triggers

✅ Avoid these frequent mistakes:

  • Incomplete prescriber specialty information
  • Missing ANCA test results
  • Monotherapy prescription (without concurrent immunosuppressants)
  • Incorrect quantity (exceeding 180 caps/30 days)
  • Missing prior treatment documentation

Specialty Pharmacy Routing

OptumRx Requirements

UnitedHealthcare requires Tavneos to be dispensed through their specialty pharmacy network, with OptumRx as the preferred vendor.

Routing steps:

  1. Prescriber submits prescription to OptumRx via ePrescribe or fax
  2. OptumRx initiates prior authorization process
  3. Patient receives contact from OptumRx for delivery coordination
  4. Copay assistance programs administered through OptumRx

Patient Support Programs

Tavneos Connect Copay Program:

  • Eligible commercially insured patients may pay as little as $0/month
  • Contact: 1-833-TAVNEOS (1-833-828-6367), option 2

After Submission: Tracking Your Request

Timeline Expectations

Step Timeline Action Required
Initial review 24-72 hours Monitor for requests for additional information
Standard determination 15 calendar days Check status via provider portal
Urgent determination 72 hours Requires physician attestation of urgency

Status Monitoring

✅ Record confirmation numbers from all submissions
✅ Check provider portal every 2-3 business days
✅ Document all communications with UnitedHealthcare
✅ Maintain copies of all submitted documents

Denial Prevention Tips

Five Common Pitfalls and Solutions

  1. Pitfall: Prescribing as monotherapy
    Solution: Always include concurrent immunosuppressive therapy in prescription
  2. Pitfall: Non-specialist prescriber
    Solution: Ensure prescription comes from rheumatology, nephrology, pulmonology, or vascular medicine
  3. Pitfall: Missing ANCA documentation
    Solution: Include positive anti-PR3 or anti-MPO test results in submission
  4. Pitfall: Inadequate prior treatment history
    Solution: Document specific previous therapies, durations, and reasons for discontinuation
  5. Pitfall: Incomplete liver function monitoring plan
    Solution: Include baseline LFTs and monitoring schedule in documentation

Washington State Appeals Process

Internal Appeals with UnitedHealthcare

First level: Standard appeal within 180 days of denial Second level: May be available depending on plan type

External Review Through IRO

Washington state provides strong consumer protection through Independent Review Organizations (IROs).

Key advantages:

  • No cost to patient for external review
  • Binding decision on UnitedHealthcare
  • Specialist reviewers with relevant medical expertise
  • 30-52% overturn rate for medical necessity denials (industry average)

Process:

  1. Complete internal appeals first
  2. Request external review within 180 days of final internal denial
  3. Submit additional evidence to IRO
  4. Receive binding decision within 30 days (72 hours for expedited)

Washington Office of Insurance Commissioner:

When facing complex denials, Counterforce Health helps patients and clinicians prepare targeted appeals that align with payer-specific requirements and Washington's external review process.

Printable One-Page Checklist

Before Submission

  • Patient age 18+ verified
  • GPA/MPA diagnosis documented
  • ANCA test results (anti-PR3 or anti-MPO positive)
  • Specialist prescriber confirmed
  • Concurrent immunosuppressive therapy prescribed
  • Prior treatment history documented
  • Baseline lab work completed
  • PA form completed fully

Submission

  • Submitted via UnitedHealthcare provider portal
  • Confirmation number recorded
  • OptumRx notified of prescription
  • Patient enrolled in copay assistance program

Follow-up

  • Status checked every 2-3 business days
  • Additional information requests addressed promptly
  • Denial response plan prepared
  • Appeal deadlines noted (180 days for internal, 180 days for external)

FAQ

Q: How long does UnitedHealthcare prior authorization take for Tavneos in Washington? A: Standard determinations take up to 15 calendar days. Urgent requests (with physician attestation) are processed within 72 hours.

Q: What if Tavneos is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. UnitedHealthcare may approve non-formulary drugs when medically necessary and no suitable alternatives exist.

Q: Can I request an expedited appeal if denied? A: Yes, if your physician attests that delay could seriously jeopardize your health. Expedited appeals are processed within 72 hours.

Q: Does step therapy apply if I've tried treatments outside Washington? A: Yes, prior treatment history from any location counts toward step therapy requirements. Ensure all previous therapies are documented in your medical records.

Q: What happens if I lose my appeal? A: In Washington, you can request external review by an Independent Review Organization (IRO). This provides an independent medical review with binding authority over UnitedHealthcare's decision.

Q: How much does Tavneos cost without insurance? A: Retail pricing is approximately $17,000 per month. The Tavneos Patient Assistance Program may provide medication at no cost for qualifying uninsured patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies may vary by plan and are subject to change.

For personalized assistance with insurance denials and appeals, visit Counterforce Health to learn how their platform helps turn denials into successful approvals through evidence-backed, payer-specific appeals.

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