By Counterforce Health Team in Krystexxa (pegloticase) —

Get Krystexxa (Pegloticase) Approved by Humana in Ohio: Complete Coverage Guide

Answer Box: Getting Started

Krystexxa (pegloticase) requires prior authorization from Humana in Ohio. Your rheumatologist must document failed trials of allopurinol and febuxostat, submit G6PD test results, and provide serum uric acid levels above 6 mg/dL. Humana typically decides within 30 days for pre-service requests. If denied, you have 65 days to appeal internally, then 60 days for external review through an Independent Review Entity. Start today: Have your doctor gather documentation of prior failed gout medications and submit the prior authorization request through Humana's provider portal.

Table of Contents

Is Krystexxa Covered by Humana?

Yes, Krystexxa (pegloticase) is covered by Humana Medicare Advantage plans, but it requires prior authorization and meets strict medical necessity criteria. The medication is classified as a specialty drug under Tier 4 (Specialty Tier) for Part D coverage, though it's often covered under Part B when administered in a clinical setting.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all plans Humana PA List
Formulary Tier Tier 4 (Specialty) Humana Drug List
Step Therapy Must fail allopurinol/febuxostat first Step Therapy List
G6PD Testing Required before first infusion FDA Label Requirements
Prescriber Rheumatologist preferred Humana Medical Policy
Administration IV infusion every 2 weeks J2507 billing code

Who Submits the Prior Authorization?

Your prescribing physician (typically a rheumatologist) submits the prior authorization request to Humana. You cannot submit this yourself as a patient.

Step-by-Step: Fastest Path to Approval

  1. Schedule rheumatology consultation - Humana prefers specialist prescribers
  2. Complete G6PD testing - Required before any infusion; contraindicated if deficient
  3. Document failed therapies - Must show inadequate response to maximized allopurinol and febuxostat
  4. Gather lab results - Serum uric acid levels consistently above 6 mg/dL
  5. Submit PA request - Doctor uses Humana provider portal
  6. Include methotrexate plan - Co-therapy may be required by Humana policy
  7. Track status - Follow up within 2 weeks if no response
Tip: Start the G6PD test early. This single lab result can delay your entire approval if missing from the initial submission.

How Long Does Approval Take?

Standard Timeline:

  • Pre-service decisions: 30 calendar days
  • Post-service decisions: 60 calendar days
  • Expedited reviews: 72 hours (if health at risk)

What if it's urgent? Request an expedited review if your gout is severely impacting your health or causing disability. Your doctor must document the medical urgency in the request.

What Clinical Criteria Must I Meet?

Humana requires documentation of all the following:

Medical Necessity Checklist:

  • ✅ Chronic gout diagnosis with tophi or chronic gouty arthropathy
  • ✅ Failed maximum tolerated doses of allopurinol (typically 800mg daily)
  • ✅ Failed maximum tolerated doses of febuxostat (typically 120mg daily)
  • ✅ Contraindication or intolerance to uricosuric agents (if appropriate)
  • ✅ Serum uric acid persistently >6 mg/dL despite treatment
  • ✅ G6PD deficiency testing (must be negative)
  • ✅ Discontinuation of oral urate-lowering therapy before starting Krystexxa
Clinician Corner: Your medical necessity letter should specifically address each failed therapy, including doses tried, duration of treatment, and reason for discontinuation (inadequate response, side effects, or contraindication). Include relevant lab values and dates.

What Will This Cost Me?

For Medicare Part D (Specialty Tier):

  • Coinsurance: Typically 33% or higher after deductible
  • 2026 plans: $2,100 annual maximum out-of-pocket cap

For Medicare Part B (Clinical Administration):

  • Coinsurance: 20% after annual Part B deductible
  • No annual out-of-pocket maximum

Cost-Saving Options:

  • Amgen By Your Side patient support program
  • Medicare Extra Help for prescription costs
  • State pharmaceutical assistance programs

The drug cost alone can exceed $30,000 per infusion, making coverage approval essential.

Common Denial Reasons and How to Fix Them

Most Common Denials:

Denial Reason How to Fix
Missing G6PD test Submit negative G6PD lab result
Insufficient prior therapy Document maximized doses of allopurinol AND febuxostat with dates/outcomes
Non-specialist prescriber Transfer care to rheumatologist
Missing methotrexate plan Include co-therapy protocol or contraindication justification
Inadequate documentation Submit complete treatment history with lab values

Internal Appeal Process:

  1. File within 65 days of denial notice
  2. Include all missing documentation identified in denial letter
  3. Have your doctor write a detailed medical necessity letter
  4. Humana decides within 30 days (pre-service) or 60 days (post-service)

When Do I Need to Renew Authorization?

Most Humana prior authorizations for Krystexxa are approved for 6-12 months. Your doctor will need to submit a renewal request showing:

  • Continued medical necessity
  • Treatment response (uric acid levels, tophus reduction)
  • Absence of serious adverse reactions
  • Ongoing monitoring results

Set a calendar reminder 30 days before your authorization expires to avoid treatment interruptions.

Why Was My Prescription Transferred to Specialty Pharmacy?

Krystexxa requires coordination through Humana's specialty pharmacy network, typically CenterWell Pharmacy, because:

  • It's a high-cost biologic requiring special handling
  • Administration must be coordinated with infusion centers
  • Prior authorization and benefits verification are managed centrally
  • Patient education and monitoring support are provided

This is standard practice and doesn't indicate a problem with your coverage.

Troubleshooting Common Issues

Provider Portal Problems:

  • If portal is down, fax requests to number on your denial letter
  • Keep confirmation receipts for all submissions
  • Follow up by phone if no response within expected timeframes

Missing Forms:

Communication Delays:

  • Ensure your doctor's office has your current contact information
  • Request status updates in writing for your records

Appeals Process Specific to Ohio

Ohio residents have additional appeal rights beyond Humana's internal process:

External Review Timeline:

  1. Internal Appeal: 65 days to file with Humana
  2. External Review: 60 days to request Independent Review Entity (IRE) after internal denial
  3. Ohio Department of Insurance: Can assist with process questions at 1-800-686-1526

External Review Process:

  • IRE must decide within 30 days (72 hours if expedited)
  • Decision is binding on Humana if approved
  • No cost to you for external review
Note: Self-funded employer plans follow federal ERISA rules, not Ohio state external review. Check your plan documents to confirm which process applies.

For assistance navigating Ohio's external review process, contact the Ohio Department of Insurance Consumer Services Division.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Krystexxa in Ohio? A: Standard pre-service decisions take up to 30 calendar days. Expedited reviews are completed within 72 hours if medically urgent.

Q: What if Krystexxa isn't on my formulary? A: Request a formulary exception through your doctor. Provide medical necessity documentation showing why preferred alternatives won't work.

Q: Can I get an expedited appeal in Ohio? A: Yes, if treatment delay would seriously jeopardize your health. Your doctor must document the urgency in the appeal request.

Q: Does step therapy apply if I failed these drugs in another state? A: Yes, documented failures from other states count. Ensure your new Ohio doctor has complete records of prior treatments.

Q: What happens if my appeal is denied? A: You can request external review through an Independent Review Entity within 60 days of Humana's final denial.

Q: Who pays for the G6PD test? A: This is typically covered as a standard lab test under your medical benefits, not pharmacy benefits.

From our advocates: One patient's Krystexxa approval was initially denied for "insufficient prior therapy documentation." Their rheumatologist resubmitted with a detailed timeline showing 18 months of maximized allopurinol followed by 12 months of febuxostat, including specific doses and side effects. The appeal was approved within two weeks. Thorough documentation of failed therapies is often the key difference between denial and approval.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific policy gaps, and crafting evidence-backed rebuttals. For complex specialty drugs like Krystexxa, having expert appeal support can significantly improve your chances of approval, especially when dealing with Humana's detailed prior authorization requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with Humana and consult with your healthcare provider about treatment decisions. For personalized assistance with your specific situation, contact Counterforce Health or the Ohio Department of Insurance Consumer Services Division.

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