By Counterforce Health Team in Turalio (pexidartinib) —

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

Answer Box: Your Fastest Path to Turalio Coverage

Likely eligible if you have: Confirmed TGCT diagnosis via MRI, surgery documented as inappropriate due to morbidity risks, and completed REMS enrollment. First step today: Have your prescriber verify REMS certification at TuralioREMS.com and gather MRI reports showing TGCT diagnosis. Timeline: Humana processes prior authorizations within 30 days for Medicare Advantage, 7 days for Part D. Washington advantage: Strong external review process through certified Independent Review Organizations if initially denied.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible
  4. If You're Possibly Eligible
  5. If You're Not Yet Eligible
  6. If Your Request Is Denied
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Washington State Appeals Process
  10. FAQ

How to Use This Decision Tree

This guide helps Washington residents navigate Humana's prior authorization process for Turalio (pexidartinib), a specialty medication for tenosynovial giant cell tumor (TGCT). Start with the eligibility triage below to determine your approval likelihood, then follow the corresponding action plan.

Important note: Humana has one of the lowest prior authorization denial rates among major insurers at approximately 3.5%, but denials typically result from incomplete documentation rather than blanket coverage restrictions.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible (High approval probability)

You meet all of these criteria:

  • Confirmed TGCT diagnosis via MRI imaging showing tenosynovial giant cell tumor
  • Surgery documented as inappropriate due to unacceptable morbidity risk or infeasibility
  • REMS enrollment completed by prescriber, patient, and pharmacy
  • Baseline liver function tests completed (ALT, AST, bilirubin, alkaline phosphatase)
  • No contraindicated medications or severe liver disease

⚠️ Possibly Eligible (Moderate approval probability)

You have:

  • TGCT diagnosis confirmed but surgical assessment incomplete or unclear
  • REMS enrollment in progress but not fully completed
  • Some required documentation but gaps in medical necessity justification
  • Mild liver function abnormalities that may require monitoring adjustments

❌ Not Yet Eligible (Low approval probability)

You have:

  • No confirmed TGCT diagnosis or imaging pending
  • Surgery recommended as viable option without documented contraindications
  • REMS enrollment not initiated
  • Significant liver disease or contraindicated medications
  • Alternative treatments not tried when clinically appropriate

If You're Likely Eligible

Document Checklist

Gather these materials before submitting your prior authorization:

Medical Documentation:

  • MRI report confirming TGCT diagnosis
  • Surgical consultation explicitly stating surgery is inappropriate due to morbidity risk
  • Baseline liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
  • Treatment history showing symptom severity and functional limitations

REMS Requirements:

  • Prescriber REMS certification completed at TuralioREMS.com
  • Patient enrollment form signed
  • Pharmacy authorization confirmed

Submission Path

  1. Contact Humana at the member services number on your insurance card
  2. Submit via prescriber through Humana's electronic prior authorization system
  3. Include all documentation from the checklist above
  4. Timeline: Allow 30 days for Medicare Advantage, 7 days for Part D decisions
Tip: Request expedited review (24-72 hours) if your condition requires urgent treatment with prescriber documentation of medical urgency.

If You're Possibly Eligible

Tests and Documentation to Request

Missing Surgical Assessment:

  • Request consultation with orthopedic or surgical oncologist
  • Ensure assessment explicitly addresses why surgery would cause "unacceptable morbidity"
  • Document tumor location, size, and surgical risks

REMS Enrollment Gaps:

  • Call REMS Program at 1-833-TURALIO (1-833-887-2546)
  • Complete any missing prescriber, patient, or pharmacy enrollment steps
  • Verify all parties are certified before prior authorization submission

Clinical Documentation:

  • Request comprehensive treatment notes showing functional limitations
  • Obtain updated MRI if previous imaging is older than 6 months
  • Document any failed alternative treatments

Timeline to Re-apply

Complete missing documentation within 2-4 weeks, then resubmit prior authorization. Humana's 30-day decision timeline restarts with each new submission.

If You're Not Yet Eligible

Alternatives to Discuss with Your Provider

Diagnostic Confirmation:

  • Schedule MRI to confirm TGCT diagnosis if imaging is pending
  • Consider tissue biopsy if MRI results are inconclusive
  • Obtain referral to TGCT specialist center if available

Treatment Options:

  • Discuss surgical feasibility with experienced TGCT surgeon
  • Consider imatinib or nilotinib (off-label alternatives) if appropriate
  • Explore active surveillance for asymptomatic cases

Preparing for Exception Requests

If standard criteria aren't met, prepare for formulary exception by documenting:

  • Why all formulary alternatives are inappropriate
  • Specific contraindications to preferred treatments
  • Unique clinical circumstances requiring Turalio

If Your Request Is Denied

Appeal Path Decision Tree

Step 1: Internal Appeal (First-Level)

  • Timeline: 65 days from denial notice
  • Process: Submit through Humana member portal or call member services
  • Required: Denial letter, additional clinical documentation, prescriber letter

Step 2: Peer-to-Peer Review

  • When: If clinical disagreement exists
  • Process: Prescriber requests direct discussion with Humana medical director
  • Timeline: Usually scheduled within 1-2 weeks of request

Step 3: External Review (Washington State)

  • Timeline: 180 days from final internal denial to request external review
  • Process: Submit request to Humana, which forwards to Office of the Insurance Commissioner
  • Decision: Independent Review Organization makes binding decision within 30 days

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Turalio prescriptions Humana formulary Humana PA List
REMS Enrollment Mandatory safety program TuralioREMS.com FDA REMS
Formulary Tier Tier 5 (Specialty) Humana drug list Humana Formulary
Step Therapy May apply Plan-specific Contact Humana member services
Quantity Limits Based on FDA dosing Prescription guidelines FDA prescribing information

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing TGCT diagnosis Submit MRI report with radiologist interpretation confirming TGCT
Surgery not addressed Obtain surgical consultation explicitly stating surgery inappropriate due to morbidity
REMS not completed Complete all REMS enrollment steps at TuralioREMS.com
Liver monitoring gaps Submit baseline LFTs and monitoring plan per FDA requirements
Non-formulary status Request formulary exception with medical necessity documentation

Washington State Appeals Process

Washington residents have strong protections through the state's external review process:

Step-by-Step External Review

  1. Complete Internal Appeals - Exhaust Humana's internal appeal process first
  2. Request External Review - Submit within 180 days to Humana, who forwards to OIC
  3. IRO Assignment - Office of the Insurance Commissioner assigns certified Independent Review Organization
  4. Submit Additional Information - You have 5 business days to provide extra documentation
  5. IRO Decision - Binding decision within 30 days (72 hours for expedited)

Washington Resources

  • Office of the Insurance Commissioner: 1-800-562-6900
  • Consumer Advocacy: Help with appeals and complaints
  • External Review Info: insurance.wa.gov
From our advocates: "We've seen several Washington patients successfully overturn Turalio denials through the state's IRO process, particularly when the initial denial focused on surgical alternatives without considering the patient's specific morbidity risks. The key was comprehensive documentation from both the prescriber and surgical consultant."

FAQ

Q: How long does Humana prior authorization take for Turalio in Washington? A: 30 days for Medicare Advantage Part C, 7 days for Part D. Expedited reviews available in 24-72 hours with medical urgency documentation.

Q: What if Turalio isn't on my Humana formulary? A: Request a formulary exception with prescriber documentation that formulary alternatives are inappropriate or contraindicated.

Q: Can I get Turalio while my appeal is pending? A: Yes, you can request continued coverage during appeals or pay out-of-pocket and seek reimbursement if appeal succeeds.

Q: Does Washington's external review cost anything? A: No, external review through Washington's IRO process is free to patients.

Q: What happens if I need Turalio urgently? A: Request expedited prior authorization (24-72 hours) with prescriber documentation of medical urgency.

Q: How do I find REMS-certified pharmacies? A: Contact the REMS Program at 1-833-TURALIO or visit TuralioREMS.com for certified pharmacy locations.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to create targeted, evidence-backed responses. The platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for specialty medications like Turalio.

For additional support with your Turalio prior authorization or appeal, Counterforce Health can help analyze your specific situation and develop a customized approval strategy based on Humana's requirements and Washington state regulations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and requirements may change. Verify current information with official sources before making healthcare decisions.

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