By Counterforce Health Team in Voydeya (danicopan) —

The Requirements Checklist to Get Voydeya (Danicopan) Covered by UnitedHealthcare in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Voydeya Covered by UnitedHealthcare in Georgia

Eligibility: Adults with PNH experiencing extravascular hemolysis despite C5 inhibitor therapy (eculizumab/ravulizumab). Fastest path: Submit prior authorization through OptumRx with documented EVH evidence, vaccination records, and specialist attestation. Start today: Verify your plan requires PA via the UnitedHealthcare provider portal and gather flow cytometry results, current lab values, and C5 inhibitor treatment history. Georgia allows 60 days for external review after internal appeal denial.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Essentials
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: What to Track
  9. Common Denial Prevention Tips
  10. Appeals Process in Georgia
  11. Printable Checklist

Who Should Use This Checklist

This guide is designed for patients, caregivers, and healthcare teams seeking UnitedHealthcare coverage for Voydeya (danicopan) in Georgia. You'll need this if:

  • Your doctor prescribed Voydeya as add-on therapy to your current C5 inhibitor
  • You received a prior authorization denial from OptumRx
  • You're experiencing ongoing anemia despite eculizumab (Soliris) or ravulizumab (Ultomiris)
  • Your specialty pharmacy requested additional documentation

Expected outcome: With complete documentation, most medically appropriate Voydeya requests receive approval within 7-14 business days. If denied, Georgia's external review process has helped many patients overturn wrongful denials for specialty medications.

Member & Plan Basics

Coverage Verification Steps

Before starting, confirm these essential details:

✓ Active UnitedHealthcare coverage through your member portal
✓ Plan type: Commercial, Medicare Advantage, or Medicaid managed care
✓ Pharmacy benefit manager: Most UHC plans use OptumRx for specialty drugs
✓ Formulary status: Check if Voydeya requires prior authorization
✓ Deductible status: Specialty tier copays may apply after deductible is met

Tip: Call the member services number on your insurance card to confirm Voydeya is covered under your pharmacy benefit (not medical benefit) and requires OptumRx prior authorization.

Plan-Specific Considerations

Plan Type PA Pathway Key Differences
Commercial (employer) OptumRx specialty PA Standard review timeline
Medicare Advantage OptumRx with CMS oversight Expedited appeals available
Medicaid managed May vary by Georgia plan Different appeal rights

Clinical Criteria Requirements

Primary Indication Requirements

Voydeya is FDA-approved for extravascular hemolysis in adults with PNH as add-on therapy. UnitedHealthcare typically requires:

  1. Confirmed PNH diagnosis by flow cytometry showing complement-mediated hemolysis
  2. Current stable dosing of eculizumab or ravulizumab for ≥3 months
  3. Evidence of ongoing EVH despite optimized C5 inhibitor therapy
  4. Specialist prescriber (hematologist experienced in PNH management)

Laboratory Evidence of EVH

Document persistent anemia with these values while on C5 inhibitor:

  • Hemoglobin: Typically <10 g/dL or requiring transfusions
  • Reticulocyte count: Elevated (>2.5% or absolute count >100,000/μL)
  • LDH: May remain elevated due to extravascular hemolysis
  • Indirect bilirubin: Often elevated
  • Haptoglobin: Low or undetectable
Clinical Note: Unlike intravascular hemolysis markers that improve with C5 inhibitors, EVH continues to cause anemia and fatigue in many PNH patients.

Step Therapy & Contraindications

UnitedHealthcare may require:

  • Trial and documentation of optimized C5 inhibitor dosing
  • Evidence that increasing C5 inhibitor dose is not appropriate
  • Documentation of transfusion requirements or quality-of-life impact

Contraindications to document:

  • Active serious infection (temporary)
  • Hypersensitivity to danicopan

Coding & Billing Essentials

ICD-10 Diagnosis Code

Primary diagnosis: D59.5 (Paroxysmal nocturnal hemoglobinuria)

HCPCS/NDC Information

  • NDC numbers: Verify current NDC with your specialty pharmacy
  • HCPCS J-code: No specific J-code established for Voydeya as of 2024
  • Units: Based on prescribed strength (150mg or 200mg TID)
  • Days supply: Typically 30-day fills through specialty pharmacy
Billing Note: Voydeya is an oral medication dispensed through specialty pharmacy, not a provider-administered drug requiring J-codes.

Documentation Packet

Medical Necessity Letter Components

Your hematologist's letter should include:

  1. Patient identification and insurance details
  2. PNH diagnosis confirmation with flow cytometry results and date
  3. Current C5 inhibitor therapy (drug, dose, duration, response)
  4. EVH evidence with specific lab values and dates
  5. Prior therapies tried and outcomes
  6. Clinical rationale for Voydeya addition
  7. Dosing plan and monitoring schedule

Required Attachments

Clinical documentation:

  • Flow cytometry report confirming PNH diagnosis
  • Recent lab results (CBC with diff, retic count, LDH, bilirubin)
  • C5 inhibitor treatment records
  • Transfusion history (if applicable)

Safety documentation:

  • Vaccination records (meningococcal, pneumococcal, Haemophilus influenzae type b)
  • REMS program acknowledgment
  • Infection screening results

Administrative documents:

  • Completed prior authorization form
  • Prescriber attestation of medical necessity
  • Patient insurance card copy

Submission Process

OptumRx Prior Authorization

Primary submission method: Electronic via CoverMyMeds

Required form: Use current OptumRx Prior Authorization Request Form (verify version on their forms page)

Common rejection causes:

  • Incomplete prescriber information
  • Missing DEA number or NPI
  • Incorrect member ID format
  • Unsigned medical necessity letter
Submission Tip: Submit electronically when possible for faster processing and automatic confirmation receipts.

Alternative Submission Methods

If electronic submission isn't available:

  • Fax: Use the fax number listed on your denial letter or PA form
  • Portal upload: Through UnitedHealthcare provider portal
  • Mail: Only as last resort due to processing delays

Specialty Pharmacy Coordination

Preferred Network Pharmacies

UnitedHealthcare typically contracts with:

  • OptumRx specialty pharmacy network
  • Accredo (Express Scripts)
  • CVS Specialty (for some plans)

Verify your plan's preferred pharmacy before prescription transfer to avoid coverage issues.

Transfer Process

  1. Prescriber sends prescription to preferred specialty pharmacy
  2. Pharmacy initiates prior authorization if not already approved
  3. Patient completes enrollment and insurance verification
  4. Shipment coordination for temperature-sensitive delivery

After Submission: What to Track

Confirmation & Status Monitoring

Record these details:

  • Prior authorization reference number
  • Submission date and method
  • Pharmacy contact information
  • Expected decision timeline

Status check schedule:

  • Day 3: Confirm receipt by OptumRx
  • Day 7: Check for requests for additional information
  • Day 10-14: Follow up if no decision received

Decision Documentation

If approved: Save approval letter with effective dates and any limitations

If denied: Note specific denial reasons and gather additional evidence for appeal

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Missing vaccination documentation: Submit complete REMS program compliance records
  2. Inadequate EVH evidence: Include recent labs showing persistent anemia despite C5 therapy
  3. Non-specialist prescriber: Ensure hematologist or PNH specialist submits the request
  4. Incomplete C5 inhibitor history: Document current therapy duration and dosing
  5. Generic medical necessity letter: Customize letter with patient-specific clinical details
Pro Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each payer's specific policies.

Appeals Process in Georgia

UnitedHealthcare Internal Appeals

Timeline for filing: Within 6 months of denial discovery
Response timeframes:

  • Pre-service (before treatment): 30 days
  • Post-service (after treatment): 60 days
  • Expedited appeals: 72 hours

Required steps:

  1. Submit claim reconsideration request first
  2. If denied, file formal internal appeal
  3. Include additional clinical evidence addressing denial reasons

Georgia External Review

After exhausting internal appeals:

Filing deadline: 60 days from final internal denial
Process: Submit application to Georgia Department of Insurance
Cost: Free to consumers
Timeline: 30 business days (72 hours for expedited)

Contact information: Georgia Office of Commissioner of Insurance and Fire Safety
Consumer Services: 1-800-656-2298

Georgia-Specific Right: You can request external review concurrent with expedited internal appeal if delay poses serious health risks.

Printable Checklist

Pre-Submission Verification

  • Active UnitedHealthcare coverage confirmed
  • OptumRx manages pharmacy benefits
  • PNH diagnosis by flow cytometry documented
  • Currently on stable C5 inhibitor therapy ≥3 months
  • Recent labs show EVH evidence
  • All required vaccinations completed
  • Hematologist willing to prescribe and attest

Documentation Packet

  • Completed OptumRx PA form (current version)
  • Medical necessity letter with specific clinical details
  • Flow cytometry report
  • Recent CBC, reticulocyte count, LDH, bilirubin
  • C5 inhibitor treatment records
  • Vaccination documentation
  • REMS program compliance

Submission & Follow-up

  • Electronic submission via CoverMyMeds preferred
  • PA reference number recorded
  • Specialty pharmacy coordination initiated
  • Status check scheduled for day 3, 7, and 14
  • Appeal strategy prepared if denied

When navigating insurance coverage for specialty medications like Voydeya, having the right documentation and understanding your appeal rights in Georgia can make the difference between approval and denial. Counterforce Health helps patients and clinicians transform denials into successful appeals by analyzing payer policies and crafting evidence-based responses that address specific coverage criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Consult your healthcare provider and insurance plan for specific guidance. For assistance with Georgia insurance appeals, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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