By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Get Eylea and Lucentis Covered by Humana in California: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Started

To get Eylea or Lucentis covered by Humana in California: First, check if your plan requires step therapy through bevacizumab (Avastin). If yes, document any prior anti-VEGF treatment failures or contraindications. Submit prior authorization via the Humana provider portal with OCT imaging, visual acuity measurements, and a medical necessity letter. Standard decisions take 7-14 days; expedited reviews complete within 72 hours for urgent cases. If denied, file an appeal within 65 days and consider California's Independent Medical Review for final determination.

Start today: Gather your insurance card, recent OCT scans, and treatment history. Call Humana member services to confirm your plan's anti-VEGF coverage requirements.

Table of Contents

  1. Understanding Humana's Coverage Requirements
  2. Preparing for Your Doctor Visit
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Essentials
  5. Supporting Your Provider Through Peer-to-Peer Review
  6. Humana Appeals Process in California
  7. When to Escalate to California State Review
  8. Common Denial Reasons and Solutions
  9. Frequently Asked Questions

Understanding Humana's Coverage Requirements

Humana Medicare Advantage plans typically cover both Eylea (aflibercept) and Lucentis (ranibizumab) as Part B injectable drugs, but with important restrictions that can affect your approval timeline.

Step Therapy Requirements

As of 2025, Humana requires step therapy through bevacizumab (Avastin) before approving Eylea or Lucentis for most patients. This means you'll typically need to try Avastin first unless:

  • You've had a paid claim for Eylea/Lucentis in the past 365 days
  • You have documented contraindications or intolerance to bevacizumab
  • Your provider can demonstrate medical necessity for starting with a different agent

Coverage at a Glance

Requirement What It Means How to Meet It
Prior Authorization Approval needed before treatment Submit via Humana provider portal
Step Therapy Try Avastin first Document prior failure/intolerance or clinical contraindication
OCT Documentation Imaging proof of condition Recent OCT showing macular edema or subretinal fluid
Visual Acuity Records Functional impact evidence Snellen chart results showing vision loss
Diagnosis Confirmation ICD-10 coding required Wet AMD (H35.32), DME (E11.311), or diabetic retinopathy
Tip: Patients already receiving anti-VEGF injections from another insurer are often exempt from step therapy requirements.

Preparing for Your Doctor Visit

Your success depends heavily on thorough preparation before meeting with your ophthalmologist or retinal specialist. Come equipped with detailed information that will strengthen your case.

Essential Information to Gather

Treatment History Timeline:

  • Dates and types of all previous eye injections
  • Response to each treatment (vision improvement, OCT changes)
  • Any side effects or complications experienced
  • Reasons for discontinuing previous medications

Functional Impact Documentation:

  • Specific vision changes you've noticed
  • How symptoms affect daily activities (reading, driving, work)
  • Progression timeline of your condition
  • Any emergency department visits related to vision changes

Insurance Documentation:

  • Current Humana member ID card
  • Summary of benefits showing ophthalmology coverage
  • Any previous denial letters or prior authorization decisions
Note: Bring a written list of questions and concerns. Appointments can feel rushed, and having notes ensures you don't forget important details.

Building Your Evidence Kit

Strong clinical evidence forms the foundation of successful prior authorization requests. Work with your care team to compile comprehensive documentation.

Required Clinical Documentation

Diagnostic Imaging:

  • Recent OCT (optical coherence tomography) scans showing retinal thickness and fluid
  • Fluorescein angiography (FFA) if OCT is insufficient to confirm vascular leakage
  • Baseline and follow-up imaging to demonstrate disease progression

Visual Function Measurements:

  • Best-corrected visual acuity using standardized charts
  • Visual field testing if peripheral vision is affected
  • Contrast sensitivity measurements when available

Laboratory and Clinical Notes:

  • Hemoglobin A1c levels for diabetic patients
  • Blood pressure readings
  • Complete ophthalmologic examination notes
  • Documentation of any contraindications to alternative treatments

Supporting Literature and Guidelines

Your provider may strengthen the case by referencing:

  • FDA labeling for your specific indication
  • American Academy of Ophthalmology preferred practice patterns
  • Peer-reviewed studies supporting treatment choice
  • Professional society position statements on anti-VEGF therapy

Medical Necessity Letter Essentials

A well-crafted letter of medical necessity can make the difference between approval and denial. Counterforce Health specializes in helping patients and providers create targeted, evidence-backed appeals that address payer-specific requirements and turn denials into approvals.

Core Components Your Provider Should Include

Patient and Clinical Background:

  • Complete diagnosis with ICD-10 codes
  • Disease severity and progression timeline
  • Previous treatments attempted and outcomes
  • Current visual acuity and functional limitations

Treatment Rationale:

  • Why Eylea or Lucentis is medically necessary
  • Evidence of inadequate response to preferred alternatives
  • Contraindications to step therapy requirements
  • Expected treatment outcomes and monitoring plan

Supporting Evidence:

  • References to FDA-approved indications
  • Clinical guidelines supporting treatment choice
  • Relevant peer-reviewed literature
  • OCT images and visual acuity measurements
From our advocates: We've seen cases where providers initially submitted brief letters that were denied, but detailed resubmissions with comprehensive clinical rationale and imaging evidence led to quick approvals. The key is addressing Humana's specific coverage criteria point by point.

Supporting Your Provider Through Peer-to-Peer Review

When Humana denies an initial request, your provider can often resolve the issue through a peer-to-peer review—a direct conversation between your doctor and Humana's medical director.

How to Help Your Provider Succeed

Prepare a Concise Case Summary:

  • One-page overview of your condition and treatment history
  • Key dates and outcomes from previous therapies
  • Specific reasons why alternatives aren't appropriate
  • Your availability for any follow-up questions

Offer Scheduling Flexibility:

  • Provide multiple time windows when you can be reached
  • Ensure your provider has updated contact information
  • Be prepared to clarify details about your symptoms or treatment response

Document the Conversation:

  • Request a summary of the peer-to-peer discussion
  • Ask about any additional information requested
  • Get timeline expectations for the final decision

Humana Appeals Process in California

If your initial prior authorization is denied, California law provides strong appeal rights beyond federal Medicare requirements.

Internal Appeals Timeline

Appeal Level Who Decides Timeline How to File
Level 1 (Redetermination) Humana 7 days (standard), 72 hours (expedited) Humana member portal or call
Level 2 (IRE Review) Independent Review Entity 7 days (benefits), 72 hours (expedited) Automatic if Level 1 denied

Key Requirements:

  • File within 65 days of denial notice (extended from 60 days in 2024)
  • Include member details, drug name, and prescriber statement
  • Request expedited review if delay could harm your health

Required Documentation for Appeals

For Your Appeal Letter:

  • Copy of original denial notice
  • Updated clinical information since initial request
  • Provider statement explaining medical necessity
  • Any new imaging or test results

Supporting Medical Records:

  • Complete ophthalmologic examination notes
  • Treatment response documentation
  • Adverse event reports from alternative therapies
  • Functional vision assessment results

When to Escalate to California State Review

California offers unique protections beyond federal Medicare appeals through Independent Medical Review (IMR).

California's Independent Medical Review Process

After exhausting Humana's internal appeals, California residents can request an IMR through the Department of Managed Health Care (DMHC) for most HMO and managed care plans.

IMR Timeline and Process:

  • File within 180 days of final internal denial
  • DMHC assigns independent physician reviewers
  • Standard IMR decisions within 45 days
  • Expedited IMR decisions within 7 days (often 72 hours)
  • No cost to patients—insurers pay all review fees

When IMR is Most Effective:

  • Denials based on "not medically necessary" determinations
  • Disputes over experimental/investigational treatment classifications
  • Cases involving cutting-edge or rare disease treatments
Note: California has one of the highest IMR success rates in the nation, with many specialty medication denials being overturned by independent medical experts.

Getting Help with IMR:

  • DMHC Help Center: (888) 466-2219
  • Online IMR application available in multiple languages
  • Consumer assistance organizations like Health Consumer Alliance provide free support

Common Denial Reasons and Solutions

Understanding typical denial reasons helps you address them proactively.

Denial Reason Solution Strategy Required Documentation
Step therapy not completed Document prior bevacizumab failure/intolerance Treatment records, adverse event notes
Insufficient diagnostic evidence Submit comprehensive imaging Recent OCT, FFA if needed, visual acuity
Non-formulary status Request formulary exception Medical necessity letter, clinical guidelines
Quantity/frequency limits Justify dosing schedule FDA labeling, treatment response data
Lack of treatment response Demonstrate ongoing benefit Serial OCT scans, visual acuity improvements

Addressing Step Therapy Denials

The most common denial reason involves step therapy requirements. To overcome this:

Document Previous Treatment Failures:

  • Specific dates of bevacizumab injections
  • Lack of anatomic or visual improvement
  • Disease progression despite treatment
  • Adverse events requiring discontinuation

Provide Medical Contraindications:

  • Allergy or hypersensitivity history
  • Systemic conditions affecting drug clearance
  • Prior complications from bevacizumab
  • Clinical reasons for preferring FDA-approved agents

Frequently Asked Questions

How long does Humana prior authorization take in California? Standard decisions are made within 7-14 days. Expedited reviews for urgent cases are completed within 72 hours. You can track status through the Humana member portal.

What if Eylea or Lucentis isn't on my plan's formulary? Request a formulary exception with your prior authorization. Include a medical necessity letter explaining why covered alternatives aren't appropriate for your condition.

Can I get expedited approval if my vision is worsening quickly? Yes. Request expedited review if delays could cause irreversible vision loss. Your provider must document the urgent medical need in the request.

Does California's step therapy override law apply to Medicare plans? Federal Medicare rules generally take precedence over state laws for Medicare Advantage plans. However, California's IMR process provides additional appeal rights.

What happens if I start treatment before getting approval? You may be responsible for the full cost, which can exceed $2,000 per injection. Always wait for approval unless it's a documented emergency.

How do I find patient assistance programs for these medications? Check manufacturer websites: Eylea patient support and Lucentis patient assistance offer copay cards and foundation grants for eligible patients.

Can I appeal if Humana takes too long to respond? Yes. If Humana doesn't respond within required timeframes, your case automatically advances to the next appeal level. You can also file a complaint with the DMHC.

What's the difference between a grievance and an appeal in California? A grievance addresses service issues, while an appeal challenges coverage denials. For specialty medications, you'll typically file an appeal for medical necessity determinations.

About This Guide: This information is for educational purposes only and doesn't constitute medical advice. Coverage policies change frequently—always verify current requirements with Humana and your healthcare provider.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific rules, incorporating the right clinical evidence and procedural requirements to maximize approval success.

Sources & Further Reading

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