By Counterforce Health Team in Emgality (galcanezumab-gnlm) —

Work With Your Doctor to Get Emgality Approved by UnitedHealthcare in Michigan: Complete Provider Collaboration Guide

Answer Box: Getting Emgality Approved in Michigan

Getting Emgality (galcanezumab) covered by UnitedHealthcare in Michigan requires prior authorization and typically two failed preventive medications. Your fastest path: (1) Schedule a visit to document migraine frequency and prior treatment failures, (2) Have your doctor submit a detailed medical necessity letter through the UnitedHealthcare provider portal, and (3) If denied, pursue peer-to-peer review within 60 days. Michigan residents have strong appeal rights through DIFS external review (127 days after final denial). Start by calling your doctor's office today to schedule your documentation visit.

Table of Contents

  1. Set Your Goal: Understanding Approval Requirements
  2. Visit Preparation: What to Document
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After-Visit Documentation
  7. Respectful Persistence Strategies
  8. Michigan-Specific Appeal Rights
  9. Common Denial Reasons & Solutions
  10. FAQ

Set Your Goal: Understanding Approval Requirements

UnitedHealthcare requires prior authorization for Emgality through their pharmacy benefit manager OptumRx. Your partnership with your healthcare provider is crucial because the approval hinges on clinical documentation that only they can provide.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Prior Authorization Pre-approval required Provider submits PA request via portal
Step Therapy Try 2+ preventives first Document failure of topiramate, propranolol, or amitriptyline
Migraine Documentation Prove frequency/severity 3+ months of headache diary showing ≥4 migraine days/month
Medical Necessity Clinical justification Letter detailing functional impact and treatment rationale

Source: UnitedHealthcare CGRP Prior Authorization Requirements

Your role is to come prepared with complete information. Your doctor's role is to translate your experience into the clinical language UnitedHealthcare requires for approval.

Visit Preparation: What to Document

Before your appointment, gather comprehensive documentation to help your provider build the strongest possible case.

Symptom Timeline Preparation

Create a detailed migraine history covering the past 6-12 months:

  • Frequency: Average migraine days per month (aim for at least 4 for chronic migraine diagnosis)
  • Severity: Rate pain levels, associated symptoms (nausea, light sensitivity)
  • Functional Impact: Missed work/school days, cancelled activities, emergency room visits
  • Triggers: Identify patterns if possible
Tip: UnitedHealthcare typically requires documentation of chronic migraine (≥15 headache days with ≥8 migraine days per month) or high-frequency episodic migraine for Emgality approval.

Treatment History Documentation

Compile a complete list of preventive medications you've tried:

Required Documentation for Each Medication:

  • Generic and brand names
  • Dosage and duration of trial
  • Specific reason for discontinuation (ineffective, side effects, contraindications)
  • Dates of treatment periods

Common Step Therapy Requirements:

  • Topiramate: Document cognitive side effects, kidney stones, or weight loss concerns
  • Propranolol: Note asthma, depression, or cardiovascular contraindications
  • Amitriptyline: Record sedation, weight gain, or cardiac concerns

Source: Michigan Migraine Treatment Guidelines

Functional Impact Assessment

Prepare specific examples of how migraines affect your daily life:

  • Work productivity losses
  • Family/social activity limitations
  • Sleep disruption patterns
  • Medication overuse concerns
  • Quality of life impacts

Consider completing validated assessment tools like HIT-6 (Headache Impact Test) or MIDAS (Migraine Disability Assessment Scale) before your visit.

Building Your Evidence Kit

Your provider needs comprehensive supporting documentation to strengthen the prior authorization request.

Essential Medical Records

Lab Results and Imaging:

  • Recent neurological workup results
  • Any MRI or CT scans ruling out secondary headaches
  • Blood work showing medication tolerance or contraindications

Clinical Documentation:

  • Previous neurology consultation notes
  • Emergency department visits for severe migraines
  • Medication trial records from pharmacy or previous providers

Published Guidelines Support

Your provider should reference current clinical guidelines supporting Emgality use:

  • American Headache Society Guidelines for CGRP inhibitor use
  • FDA-approved labeling for galcanezumab in migraine prevention
  • Clinical trial data demonstrating efficacy in treatment-resistant patients

Medication History Summary

Create a chronological summary of all migraine treatments:

  1. Over-the-counter phase: What you tried before seeking prescription help
  2. Acute treatment trials: Triptans, NSAIDs, combination medications
  3. Preventive medication failures: Detailed documentation as outlined above
  4. Current rescue medication use: Frequency and effectiveness

Medical Necessity Letter Structure

Your provider's medical necessity letter is the cornerstone of approval. Here's what it should include:

Required Components

Patient Demographics and Diagnosis:

  • Full name, DOB, UnitedHealthcare member ID
  • ICD-10 diagnosis code (G43.709 for chronic migraine)
  • Clear statement of migraine frequency and pattern

Clinical Rationale:

  • Detailed description of migraine impact on function
  • Documentation of failed preventive therapies (minimum 2)
  • Explanation of why Emgality is medically necessary
  • Contraindications to alternative treatments

Treatment Plan:

  • Proposed Emgality dosing (240mg loading dose, then 120mg monthly)
  • Monitoring plan and success metrics
  • Duration of intended treatment

Supporting Evidence:

  • References to FDA labeling and clinical guidelines
  • Peer-reviewed studies supporting use in similar patients
  • Professional society recommendations
From Our Advocates: We've seen approval rates improve significantly when providers include specific functional impact metrics (like "patient misses 8+ work days monthly due to migraines") rather than generic statements about pain. Quantifiable impacts resonate with utilization review teams.

Supporting Peer-to-Peer Reviews

If the initial prior authorization is denied, your provider can request a peer-to-peer review with a UnitedHealthcare medical director.

How to Support Your Provider

Offer Scheduling Flexibility:

  • Provide multiple time windows when you're available for discussion
  • Ensure your provider has your current contact information
  • Be prepared to join the call if requested

Prepare a Concise Case Summary:

  • One-page summary of your migraine history
  • Clear timeline of treatment failures
  • Specific examples of functional limitations

Key Information for Peer-to-Peer:

  • UnitedHealthcare peer-to-peer requests: 800-955-7615 (verify current number)
  • Must be requested within 60 days of denial
  • Scheduling typically occurs within 24 business hours

Source: UnitedHealthcare Peer-to-Peer Process Guidelines

After-Visit Documentation

Maintain organized records of all interactions and submissions.

What to Save

From Your Provider Visit:

  • Copy of medical necessity letter
  • Prior authorization submission confirmation
  • Any additional clinical notes or assessments
  • Provider's direct contact information for follow-up

Communication Records:

  • Portal messages regarding your case
  • Phone call logs with reference numbers
  • Email confirmations of document submissions

Portal Communication Best Practices

When Messaging Your Provider:

  • Use clear subject lines: "Emgality PA Follow-up - [Your Name]"
  • Include relevant dates and reference numbers
  • Ask specific questions rather than general status updates
  • Respect response timeframes (typically 1-2 business days)

Respectful Persistence Strategies

Appropriate follow-up helps ensure your case doesn't fall through administrative cracks.

Follow-Up Cadence

Week 1-2: Allow processing time, no contact needed Week 3: Gentle status inquiry via patient portal Week 4+: Phone follow-up if no response to portal messages

Escalation Approaches

Within Your Provider's Office:

  1. Start with medical assistant or nurse
  2. Request to speak with office manager if needed
  3. Ask for provider callback for complex issues

With UnitedHealthcare:

  1. Member services for general status: 1-800-711-4555
  2. OptumRx for pharmacy-specific issues: 1-800-711-4555
  3. Formal complaint if service issues persist

Michigan-Specific Appeal Rights

Michigan residents have strong protections for insurance appeal processes through the Department of Insurance and Financial Services (DIFS).

Internal Appeals with UnitedHealthcare

Timeline:

  • Pre-service denials: 30 calendar days for decision
  • Post-service denials: 60 calendar days for decision
  • You have 180 days from denial to file internal appeal

External Review Through Michigan DIFS

If UnitedHealthcare upholds the denial after internal appeal:

Key Facts:

  • 127 days from final denial to request external review
  • Standard review: decision within 60 days
  • Expedited review: decision within 72 hours (requires physician certification of urgency)
  • Decision is binding on UnitedHealthcare

How to File:

Source: Michigan Patient's Right to Independent Review Act

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient prior therapy trials Document 2+ failed preventives Medication history with doses, duration, reasons for failure
Inadequate migraine frequency Provide detailed headache diary 3+ months showing ≥4 migraine days/month
Not medically necessary Strengthen clinical justification Functional impact assessment, validated disability scores
Step therapy not met Request exception or complete trials Medical contraindications or previous failure documentation
Quantity limits exceeded Justify dosing requirements Provider attestation of appropriate dosing per FDA label

Costs and Assistance Programs

While working toward insurance approval, explore financial assistance:

Eli Lilly Emgality Savings Program:

  • May reduce copays to $5/month for eligible patients
  • Commercial insurance required (not government plans)
  • Visit manufacturer website to verify current eligibility

Patient Assistance Programs:

  • Income-based free medication programs
  • Typically for uninsured or underinsured patients
  • Application through Eli Lilly patient support services

FAQ

How long does UnitedHealthcare prior authorization take in Michigan? Standard prior authorization decisions are typically made within 15 business days. Urgent requests may be processed within 24-72 hours.

What if Emgality isn't on my UnitedHealthcare formulary? Non-formulary medications require additional documentation but can still be approved through medical exception processes. Your provider will need to demonstrate medical necessity and lack of formulary alternatives.

Can I request an expedited appeal in Michigan? Yes, if delay would seriously jeopardize your health or ability to regain maximum function. Your provider must certify the urgency in writing.

Does Michigan step therapy apply if I failed preventives in another state? Yes, documented treatment failures from other states should count toward step therapy requirements. Ensure your new Michigan provider has complete records.

How much does Emgality cost without insurance in Michigan? List price is approximately $741.69 per 120mg pen. Manufacturer discount programs and pharmacy coupons may reduce costs to $690-870 monthly.

What happens if Michigan DIFS external review denies my appeal? You can appeal the DIFS decision to Michigan circuit court within 60 days, though this requires legal representation in most cases.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements. For complex cases like Emgality approvals, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals with required clinical facts and procedural requirements. Learn more at www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For additional help with Michigan insurance appeals, contact DIFS at 877-999-6442.

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