By Counterforce Health Team in Pemazyre (pemigatinib) —

Do You Qualify for Pemazyre (Pemigatinib) Coverage by Humana in Washington? Decision Tree & Next Steps

Answer Box: Your Path to Pemazyre Coverage

Most patients with FGFR2 fusion-positive cholangiocarcinoma or FGFR1-rearranged myeloid/lymphoid neoplasms qualify for Pemazyre coverage by Humana in Washington. The fastest path: ensure you have documented FGFR testing results, complete baseline ophthalmologic exam, and submit prior authorization with these documents via your prescriber. First step today: Contact your oncologist to confirm FGFR testing is complete and schedule the required eye exam. If denied, Washington's external review process through certified Independent Review Organizations gives you strong appeal rights within 60 days.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Approval Checklist
  4. If "Possibly Eligible" - Tests and Timeline
  5. If "Not Yet" - Alternative Paths
  6. If Denied - Washington Appeal Process
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. FAQ: Pemazyre Coverage in Washington
  10. Resources & Next Steps

How to Use This Decision Tree

This guide helps you determine if you qualify for Pemazyre (pemigatinib) coverage through Humana in Washington and provides your exact next steps. Work through the eligibility questions below, then follow the appropriate path.

Before you start, gather these documents:

  • Insurance card and member ID
  • Complete diagnosis and staging information
  • FGFR testing results (if completed)
  • List of previous cancer treatments
  • Current prescriber contact information

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

For Cholangiocarcinoma (bile duct cancer):

  • ✅ Yes: Unresectable, locally advanced, or metastatic cholangiocarcinoma
  • ✅ Yes: Previously treated (at least one prior systemic therapy)
  • ❌ No: Early-stage, resectable disease

For Myeloid/Lymphoid Neoplasms:

  • ✅ Yes: Relapsed or refractory myeloid/lymphoid neoplasm
  • ✅ Yes: No satisfactory alternative treatment options
  • ❌ No: Newly diagnosed, untreated disease

Step 2: FGFR Testing Status

Required molecular testing:

  • ✅ FGFR2 fusion/rearrangement (for cholangiocarcinoma)
  • ✅ FGFR1 rearrangement (for myeloid/lymphoid neoplasms)
  • ❌ No FGFR alteration found
  • ❓ Testing not yet completed

Step 3: Safety Requirements

Ophthalmologic monitoring:

  • ✅ Can complete baseline comprehensive eye exam with OCT
  • ✅ Can attend follow-up eye exams every 2-3 months
  • ❌ Unable to comply with eye monitoring

If "Likely Eligible" - Your Approval Checklist

You have the right diagnosis, confirmed FGFR alteration, and can complete safety monitoring. Here's your path to approval:

Document Checklist for Prior Authorization

Essential Clinical Documents:

  1. Pathology report confirming FGFR2 fusion or FGFR1 rearrangement
  2. Staging studies showing unresectable/metastatic disease
  3. Treatment history documenting prior systemic therapies
  4. Baseline ophthalmologic exam with OCT results
  5. Monitoring plan for ongoing eye exams

Submission Process

  1. Contact your oncologist to initiate prior authorization
  2. Prescriber submits to Humana via fax: 1-877-486-2621
  3. Expected timeline: 72 hours for standard PA decision
  4. Expedited option: 24 hours if medically urgent
Tip: Request expedited review if treatment delay could worsen your prognosis. Your oncologist can justify urgency based on disease progression.

If "Possibly Eligible" - Tests and Timeline

You meet diagnostic criteria but need additional testing or documentation.

Missing FGFR Testing

Next steps:

  1. Request FGFR testing from your oncologist immediately
  2. Testing options: NGS panel or FISH assay at CLIA-certified lab
  3. Timeline: 7-14 days for results
  4. Coverage: Most insurers cover companion diagnostic testing for eligible patients

Washington testing resources:

  • UW Medicine laboratories
  • Fred Hutch Cancer Center
  • National reference labs (Foundation Medicine, Caris)

Missing Safety Monitoring Setup

Ophthalmologic requirements:

  1. Schedule baseline exam with comprehensive ophthalmologist
  2. Ensure OCT capability at the practice
  3. Confirm follow-up availability every 2-3 months
  4. Document monitoring plan for PA submission

If "Not Yet" - Alternative Paths

You don't currently meet standard criteria but may have options.

FGFR-Negative Results

Discuss with your oncologist:

  • Repeat testing if initial sample was inadequate
  • Liquid biopsy as alternative testing method
  • Standard chemotherapy options (gemcitabine/cisplatin for cholangiocarcinoma)

Off-Label Considerations

For non-standard indications:

  • Prepare detailed medical necessity letter
  • Gather supporting literature citations
  • Consider compassionate use programs
  • Plan for formulary exception request

If Denied - Washington Appeal Process

Washington provides strong consumer protections for insurance denials through a structured appeals process.

Internal Appeals (First Level)

Timeline: 65 days from denial date Process:

  1. Submit written appeal to Humana
  2. Include additional clinical documentation
  3. Request peer-to-peer review if appropriate
  4. Decision required within 30 days (standard) or 72 hours (expedited)

External Review (Independent)

When to use: After internal appeal denial Timeline: 60 days from final internal denial Process:

  1. Request external review from Washington Office of Insurance Commissioner
  2. Independent Review Organization (IRO) assigned automatically
  3. Submit supporting evidence within 5 business days
  4. Decision within 20 days (binding on Humana)

Contact for assistance:

From our advocates: We've seen many Pemazyre denials overturned at the external review level in Washington when patients submitted complete molecular testing documentation and demonstrated failed standard therapies. The key is thorough documentation of the FGFR alteration and treatment history.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Verify With
Prior Authorization Approval needed before dispensing Humana formulary Member services
FGFR Testing Documented molecular alteration Pathology report Your oncologist
Ophthalmologic Monitoring Baseline + ongoing eye exams Comprehensive ophthalmologist Eye care provider
Step Therapy Try other drugs first (if required) Humana policy documents Prior authorization team
Quantity Limits 30-day supply typical Plan formulary Pharmacy benefits

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
No FGFR alteration documented Submit complete molecular pathology report NGS or FISH results showing specific alteration
Insufficient prior therapy Document treatment history and failures Medical records, treatment summaries, imaging
Missing safety monitoring Establish ophthalmologic care plan Baseline exam results, monitoring schedule
Off-label use Request formulary exception Medical necessity letter, literature support
Non-formulary status Submit tier exception request Clinical justification for Pemazyre vs. alternatives

FAQ: Pemazyre Coverage in Washington

How long does Humana prior authorization take in Washington? Standard PA decisions are required within 72 hours. Expedited reviews for urgent cases must be completed within 24 hours.

What if Pemazyre is non-formulary on my Humana plan? You can request a formulary exception. Your prescriber must demonstrate medical necessity and explain why formulary alternatives are inappropriate.

Can I request an expedited appeal in Washington? Yes, both internal appeals and external reviews can be expedited if waiting would seriously jeopardize your health. The external review decision comes within 72 hours for expedited cases.

Does step therapy apply if I've tried treatments outside Washington? Yes, treatment history from any location counts toward step therapy requirements. Ensure your prescriber documents all prior therapies in the PA request.

What's the success rate for external reviews in Washington? Washington maintains transparency through its IRO decision database. Success rates vary by case type, but thorough documentation significantly improves outcomes.

How much does Pemazyre cost without insurance? Specialty oncology medications like Pemazyre typically cost in the high four- to five-figure range monthly. Manufacturer copay assistance and patient support programs may be available.

Resources & Next Steps

Getting Pemazyre covered requires coordination between you, your oncologist, and often your insurance company. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's own rules.

Take action today:

  1. Confirm FGFR testing is complete and results are available
  2. Schedule baseline ophthalmologic exam if not already done
  3. Contact your oncologist to initiate prior authorization
  4. Gather treatment history documentation for PA submission

If you need appeal assistance:

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 circumstances, plan details, and medical necessity determinations. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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