By Counterforce Health Team in Retevmo (selpercatinib) —

Work With Your Doctor to Get Retevmo (Selpercatinib) Approved by UnitedHealthcare in New York: Provider Partnership Guide

Answer Box: Getting Retevmo Covered by UnitedHealthcare in New York

To get Retevmo (selpercatinib) approved by UnitedHealthcare in New York: Your oncologist must submit a prior authorization request with confirmed RET fusion testing results and clinical documentation. If denied, you have 180 days for internal appeals and 4 months for New York State external review through the Department of Financial Services. Start today: Schedule an appointment to review your RET testing results and discuss treatment options with your oncologist.

Table of Contents

  1. Set Your Goal: Understanding What Approval Requires
  2. Visit Preparation: Gathering Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After-Visit Documentation
  7. Respectful Persistence and Follow-Up
  8. Appeals Process in New York
  9. Cost Assistance Options
  10. FAQ

Set Your Goal: Understanding What Approval Requires

Getting Retevmo (selpercatinib) covered by UnitedHealthcare requires a collaborative approach with your oncologist. This RET-selective inhibitor, manufactured by Eli Lilly and Company, costs approximately $23,000–$26,000 per month and requires prior authorization through OptumRx.

Your partnership goal: Work together to demonstrate that Retevmo is medically necessary for your RET fusion-positive cancer. UnitedHealthcare typically requires:

  • Confirmed RET alteration via FDA-approved testing (like FoundationOne CDx)
  • Documentation of your specific cancer type and stage
  • Evidence that other treatments have failed or aren't suitable
  • Clinical rationale from your oncologist
Note: UnitedHealthcare's OptumRx division manages specialty drug approvals and may apply step therapy requirements, meaning other treatments must be tried first unless medically contraindicated.

Visit Preparation: Gathering Your Medical History

Before your appointment, compile a comprehensive timeline to help your oncologist build the strongest case:

Symptom and Treatment Timeline

  • Initial diagnosis date and staging information
  • Previous treatments tried (chemotherapy, immunotherapy, radiation)
  • Treatment outcomes: response rates, progression dates, side effects
  • Current symptoms and how they impact daily activities
  • Performance status changes over time

Key Questions to Discuss

  1. What were the results of my RET testing?
  2. How does my cancer type and stage align with Retevmo's FDA approval?
  3. What alternatives have we tried or considered?
  4. What are the risks of delaying Retevmo treatment?

Bring all relevant medical records, including pathology reports, imaging results, and treatment summaries from other providers.

Building Your Evidence Kit

Your oncologist will need comprehensive documentation to support the prior authorization request. Help by organizing:

Essential Medical Records

  • RET fusion testing results from an FDA-approved platform
  • Pathology reports confirming cancer diagnosis and staging
  • Imaging studies showing disease progression or response
  • Laboratory results relevant to treatment monitoring
  • Treatment history with dates, dosing, and outcomes

Published Guidelines Support

Your oncologist will reference current treatment guidelines, including:

  • NCCN Guidelines: List selpercatinib as preferred first-line therapy for RET fusion-positive metastatic NSCLC
  • FDA labeling: Approved for RET fusion-positive NSCLC and thyroid cancers
  • ASCO recommendations: Support RET-selective inhibitors over multikinase inhibitors

Medical Necessity Letter Structure

Work with your oncologist to ensure the medical necessity letter includes these critical components:

Required Elements

  1. Patient demographics and insurance information
  2. Specific diagnosis with ICD-10 codes
  3. RET testing methodology and results
  4. Prior treatment history and outcomes
  5. Clinical rationale for Retevmo specifically
  6. Dosing and monitoring plan
  7. Literature citations supporting use

Sample Clinical Rationale Language

Your oncologist might include language such as:

"This patient has molecularly confirmed RET fusion-positive [NSCLC/thyroid cancer]. NCCN and ASCO guidelines recommend selpercatinib as the preferred first-line treatment for metastatic RET fusion-positive tumors, due to demonstrated improvements in objective response rates and progression-free survival compared to prior standard therapies."

Supporting Peer-to-Peer Reviews

If UnitedHealthcare requests a peer-to-peer review, you can support your oncologist by:

Preparation Support

  • Provide availability windows for when your oncologist can take the call
  • Summarize your case in bullet points for quick reference
  • Highlight urgent factors if treatment delays pose risks

Key Points for Your Oncologist to Emphasize

  • RET fusion-positive status confirmed by validated testing
  • Superior efficacy of RET-selective inhibitors over alternatives
  • Guidelines supporting first-line use
  • Patient-specific factors favoring Retevmo
From our advocates: "One patient's oncologist prepared for their peer-to-peer call by creating a one-page case summary with the patient's key clinical details, testing results, and guideline citations. This preparation helped the call go smoothly and led to approval within 48 hours."

After-Visit Documentation

After your appointment, ensure proper documentation and follow-up:

What to Save

  • Visit summary from your patient portal
  • Copy of prior authorization submission if available
  • Reference numbers for PA requests
  • Timeline expectations provided by clinic staff

Portal Messaging Best Practices

When communicating through your patient portal:

  • Be specific about your request
  • Include relevant dates and reference numbers
  • Ask for status updates on PA submissions
  • Request copies of denial letters immediately

Respectful Persistence and Follow-Up

Maintaining appropriate follow-up helps ensure your case doesn't get overlooked:

Follow-Up Schedule

  • Week 1: Confirm PA submission and reference number
  • Week 2: Check status if no response received
  • Week 3: Request update and discuss backup plans
  • Beyond 3 weeks: Consider escalation or appeals preparation

Escalation Strategies

If initial requests are unsuccessful:

  1. Request peer-to-peer review through your oncologist
  2. Ask about expedited review if treatment is urgent
  3. Prepare for internal appeals with additional documentation
  4. Consider external review through New York State if needed

Appeals Process in New York

New York provides strong consumer protections for insurance appeals:

Internal Appeals with UnitedHealthcare

  • Timeline: 180 days from denial to file
  • Process: Submit through provider portal or mail
  • Required documents: Denial letter, medical records, physician appeal letter
  • Decision timeframe: Standard review within 30 days, expedited within 72 hours

External Appeals Through New York DFS

If internal appeals fail, New York's Department of Financial Services offers independent review:

Requirement Patient Provider Timeline
Filing deadline 4 months from final denial 60 days from final denial 30 days standard review
Filing fee $25 (waived for Medicaid/hardship) $50 (refunded if successful) 72 hours expedited
Submission method DFS Portal, mail, or fax Same 24 hours for urgent drugs

Required Documentation for Appeals

  • Final adverse determination letter from UnitedHealthcare
  • Complete medical records supporting medical necessity
  • Physician statement addressing denial reasons
  • Published literature supporting treatment
  • External appeal application form

Cost Assistance Options

While working toward coverage approval, explore financial assistance:

Manufacturer Support

  • Lilly Cares Foundation: Income-based assistance program
  • Retevmo copay card: May reduce out-of-pocket costs for eligible patients
  • Patient assistance programs: Available through retevmo.lilly.com

Additional Resources

  • CancerCare: Free financial assistance and counseling
  • Patient Advocate Foundation: Copay relief programs
  • State pharmaceutical assistance programs: Available for eligible New York residents

Healthcare coverage navigation can be complex, and platforms like Counterforce Health specialize in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned with payer policies.

FAQ

How long does UnitedHealthcare prior authorization take for Retevmo? Standard prior authorization decisions typically take 5-15 business days. Expedited reviews for urgent cases can be completed within 72 hours.

What if Retevmo isn't on UnitedHealthcare's formulary? Non-formulary drugs can still be covered through medical necessity appeals. Your oncologist will need to demonstrate why formulary alternatives aren't appropriate.

Can I request an expedited appeal if treatment is urgent? Yes, both UnitedHealthcare and New York State external appeals offer expedited review for urgent medical situations, typically within 24-72 hours.

What happens if step therapy is required? Your oncologist can request an exception by documenting why other treatments have failed, caused intolerable side effects, or are contraindicated.

Does my RET testing need to be from a specific lab? UnitedHealthcare typically requires RET testing from FDA-approved platforms like FoundationOne CDx or other validated next-generation sequencing panels.

How much will Retevmo cost with UnitedHealthcare coverage? Costs vary by plan, but copays for specialty tiers can range from $50-$500+ per month. Manufacturer copay cards may help reduce out-of-pocket expenses.

What if I live near the New York border but have coverage from another state? Appeal rights depend on where your insurance is regulated, not where you live. Check with your state's insurance department for specific appeal procedures.

Can my oncologist appeal on my behalf? Yes, providers can file appeals for their patients and often have dedicated staff to handle prior authorization and appeals processes.

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 benefits and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage information. Counterforce Health helps patients navigate insurance appeals but cannot guarantee coverage outcomes.

For additional support with insurance appeals and prior authorization challenges, healthcare advocates and specialized platforms can provide targeted assistance in building stronger cases for coverage approval.

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