By Counterforce Health Team in Kesimpta (ofatumumab) —

Work With Your Doctor to Get Kesimpta (Ofatumumab) Approved by UnitedHealthcare in Georgia: Complete Provider Partnership Guide

Quick Answer: Getting Kesimpta Approved by UnitedHealthcare in Georgia

Kesimpta requires prior authorization from UnitedHealthcare, typically with step therapy requirements. Your best path to approval: partner closely with your neurologist to document your relapsing MS diagnosis, prior treatment failures, and medical necessity. In Georgia, you have 180 days to appeal denials internally, then 60 days for external review through the Georgia Department of Insurance. Start by scheduling a comprehensive visit with your MS specialist to review your treatment history and gather supporting documentation.

First step today: Call your neurologist's office to schedule an appointment specifically to discuss Kesimpta and prepare your prior authorization request.

Table of Contents

Set Your Goal: Understanding UnitedHealthcare's Requirements

UnitedHealthcare requires prior authorization for Kesimpta through OptumRx, with step therapy requirements in most plans. Here's what approval typically requires:

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must get approval before filling OptumRx formulary documents
Step Therapy Try other MS drugs first UnitedHealthcare member portal
Specialty Pharmacy Must use designated pharmacy Plan benefits summary
Quantity Limits 0.02 ML per dose limit OptumRx restrictions
Hepatitis B Screening Required before starting FDA prescribing information

Your partnership goal: Work with your neurologist to demonstrate that Kesimpta is medically necessary for your specific relapsing MS case and that you've tried or can't use preferred alternatives.

Tip: UnitedHealthcare's PA denial rate for Medicare Advantage was ~9% in 2023, higher than peer average, so thorough documentation is crucial.

Prepare for Your Provider Visit

Come to your appointment with organized information that helps your doctor build a strong case:

Your MS Timeline

  • First symptoms and diagnosis date
  • Relapse history: When, what symptoms, how severe, how long to recover
  • MRI dates and results: Bring reports showing new lesions or disease activity
  • Current disability level: How MS affects your daily activities, work, mobility

Treatment History Documentation

Create a comprehensive list of all MS treatments you've tried:

For each medication, note:

  • Drug name and dates used
  • Dosage and duration
  • Why you stopped (ineffective, side effects, contraindications)
  • Specific side effects experienced
  • Any hospitalizations or serious reactions

Common UnitedHealthcare step therapy requirements include:

  • Interferons (Avonex, Betaseron, Copaxone)
  • Oral medications (Aubagio, Tecfidera)
  • Other injectable DMTs

Functional Impact Notes

Document specific examples of how MS affects your life:

  • Work limitations or missed days
  • Mobility challenges
  • Cognitive symptoms
  • Impact on family responsibilities
  • Quality of life changes

Build Your Evidence Kit

Gather supporting documentation before your visit:

Required Lab Work and Imaging

  • Recent MRI reports (within 6-12 months showing active disease)
  • Hepatitis B screening results (required before Kesimpta)
  • Complete blood count and liver function tests
  • Immunoglobulin levels (if available)

Published Guidelines and Evidence

Your doctor will reference these in your medical necessity letter:

Insurance Documentation

  • Current UnitedHealthcare member ID card
  • Benefits summary showing specialty drug coverage
  • Any prior denial letters
  • Explanation of Benefits (EOB) from previous treatments

Medical Necessity Letter Structure

Work with your doctor to ensure your medical necessity letter includes these key components:

Essential Elements Checklist

Patient Information and Diagnosis:

  • Clear MS subtype diagnosis (RRMS, active SPMS, or CIS)
  • Updated ICD-10-CM codes (G35.A for RRMS, G35.C for SPMS)
  • Date of diagnosis and diagnostic criteria used

Clinical Rationale:

Prior Treatment Documentation:

  • Detailed history of previous DMTs
  • Specific reasons for discontinuation
  • Documentation of inadequate response or intolerance

Safety Considerations:

Treatment Goals and Monitoring:

  • Expected outcomes with Kesimpta
  • Monitoring plan for efficacy and safety
  • Timeline for reassessment
Clinician Corner: Include specific MRI findings, relapse rates per year, and EDSS scores when available. Reference the FDA label indication for "relapsing forms of multiple sclerosis" and cite any relevant clinical trials or real-world evidence studies.

Support Your Doctor During Peer-to-Peer Review

If UnitedHealthcare requests a peer-to-peer review, help your doctor prepare:

Offer Your Availability

  • Provide multiple time windows when your doctor can reach the medical reviewer
  • Be flexible with scheduling to avoid delays
  • Offer to be available for a three-way call if needed

Prepare a Concise Case Summary

Help your doctor create a one-page summary including:

  • Your MS diagnosis and current status
  • Prior treatments and why they failed
  • Why Kesimpta is the best option
  • Risks of delaying treatment

Key Talking Points for Your Doctor

  • Non-interchangeability: MS DMTs are not interchangeable; choice must be individualized
  • Guideline support: Reference current AAN treatment guidelines
  • Safety profile: Kesimpta's safety considerations vs. alternatives
  • Patient-specific factors: Your unique clinical situation

After Your Visit: Documentation and Follow-up

What to Save and Organize

  • Copy of the medical necessity letter
  • All supporting lab reports and imaging
  • Documentation of the PA submission
  • Reference number for your request
  • Expected timeline for decision

Portal Communication

Use UnitedHealthcare's member portal to:

  • Check PA status regularly
  • Upload additional documentation if requested
  • Communicate with your care team
  • Track appeal deadlines

Stay Connected with Your Doctor's Office

  • Ask for a dedicated contact person
  • Confirm they have your current phone number and email
  • Request updates on any insurer communications
  • Offer to help gather additional information if needed

Respectful Persistence: When and How to Follow Up

Timeline for Updates

  • Week 1: Confirm PA submission was received
  • Week 2-3: Check status if no response (standard review takes up to 15 business days)
  • After denial: Immediately discuss appeal strategy with your doctor

How to Escalate Politely

If facing delays or poor communication:

  1. Document everything: Keep records of all interactions
  2. Request supervisor involvement: Ask to speak with a case manager
  3. Involve patient advocacy: Contact UnitedHealthcare's patient advocate program
  4. Consider external help: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with the insurer's own rules.

Escalation Scripts

For delays: "I'm following up on PA request #[number] submitted on [date]. The standard timeline has passed, and I need to know the status for my MS treatment."

For denials: "I received a denial for my Kesimpta PA. I'd like to understand the specific reasons and discuss our appeal options immediately."

Appeals Process in Georgia

If your initial request is denied, Georgia provides specific protections and timelines:

Internal Appeals with UnitedHealthcare

  • Timeline: Up to 180 days from denial to file internal appeal
  • Decision timeframe: 30 days for pre-service appeals, 60 days for post-service
  • Expedited appeals: 72 hours for urgent cases
  • How to file: Submit through UnitedHealthcare member portal or by phone

External Review Through Georgia DOI

When to Request Expedited Review

  • Active MS relapse requiring immediate treatment
  • Evidence of rapidly progressing disease
  • Current treatment causing serious side effects
  • Risk of permanent disability without prompt treatment
Note: Georgia's external review process is binding on insurers and has helped many patients win coverage for specialty medications when clinical evidence supports medical necessity.

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"Step therapy not completed" Document prior DMT trials, failures, or contraindications
"Not FDA approved for your condition" Confirm relapsing MS diagnosis with proper ICD-10 coding
"Experimental/investigational" Cite FDA approval and prescribing information
"Not medically necessary" Provide evidence of active disease and treatment rationale
"Missing safety screening" Submit hepatitis B panel and vaccination records
"Quantity exceeds limits" Justify dosing based on FDA labeling

FAQ

How long does UnitedHealthcare PA take in Georgia? Standard prior authorization decisions take up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Kesimpta is non-formulary on my plan? Non-formulary drugs can still be covered with strong medical necessity documentation and evidence that formulary alternatives are inappropriate or ineffective.

Can I request an expedited appeal if my MS is worsening? Yes. Both internal appeals with UnitedHealthcare and external reviews through Georgia DOI offer expedited timelines (72 hours) for urgent medical situations.

Does step therapy apply if I tried medications in another state? Yes. Document all prior treatments regardless of where you received them. UnitedHealthcare accepts step therapy documentation from any location.

What happens if I miss the appeal deadline? Missing Georgia's 60-day external review deadline typically forfeits your right to state-level review, though rare exceptions may apply for extraordinary circumstances.

Can my doctor submit appeals on my behalf? Yes. Healthcare providers can submit both internal appeals and external review requests with proper patient authorization.

How much does Kesimpta cost if approved? Costs vary by plan. Many patients qualify for manufacturer copay assistance or foundation grants. Medicare Part D has a $2,000 annual out-of-pocket cap starting in 2025.

What if UnitedHealthcare requires a different specialty pharmacy? You must use UnitedHealthcare's designated specialty pharmacy network. Your doctor's office can help coordinate the transfer once approved.

From our advocates: "One patient we worked with had their Kesimpta initially denied for 'incomplete step therapy.' By carefully documenting their intolerance to interferons and progression on oral DMTs, plus providing detailed MRI evidence of continued disease activity, they won approval on internal appeal within two weeks. The key was having their neurologist clearly explain why each prior treatment failed and why Kesimpta was the most appropriate next step."

When to Get Professional Help

If you're struggling with denials or complex appeals, consider getting expert assistance. Counterforce Health helps patients and clinicians navigate insurance denials by creating targeted appeals that address specific payer requirements and cite appropriate medical evidence.

For additional support in Georgia:

  • Georgia Department of Insurance Consumer Services: 1-800-656-2298
  • Georgians for a Healthy Future: Nonprofit providing consumer assistance
  • National MS Society: Local chapter support and advocacy resources

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and your insurance company about specific coverage requirements. Appeal rights and timelines may vary by plan type.

Sources & Further Reading

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