By Counterforce Health Team in Onpattro (patisiran) —

Get Onpattro (Patisiran) Covered by Humana in Michigan: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Onpattro (Patisiran) Covered by Humana in Michigan

Onpattro requires prior authorization from Humana and costs ~$450,000+ annually. Your fastest path: (1) Have your neurologist submit a PA request with genetic testing confirming hATTR-PN, baseline functional assessments, and vitamin A supplementation plan; (2) If denied, file an internal appeal within 65 days; (3) Request Michigan's external review through DIFS within 127 days of final denial. Start today by calling Humana at 1-800-555-2546 to request PA forms and confirm your plan's specific requirements.

Table of Contents

Understanding Your Coverage

Onpattro (patisiran) is a groundbreaking siRNA therapy for hereditary transthyretin-mediated amyloidosis with polyneuropathy (hATTR-PN). At approximately $450,000-$500,000 annually, it's among the most expensive medications covered by insurance, making proper authorization critical.

Humana Coverage Status:

  • Prior Authorization Required: Yes, for all plans
  • Formulary Status: Covered with restrictions
  • Clinical Outcomes Monitoring: Required via Evio's secure portal
  • Billing Requirements: Must include NDC code with HCPCS J0222
Note: Humana has one of the lowest PA denial rates (~3.5%) among major Medicare Advantage plans, but denials often stem from incomplete documentation rather than medical necessity disputes.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed
Age 18+ years Date of birth verification
Diagnosis Confirmed hATTR-PN Genetic testing showing pathogenic TTR variant
Prescriber Neurologist or specialist Provider credentials and specialty
Genetic Confirmation Pathogenic TTR mutation Lab report from certified genetic testing lab
Functional Assessment Baseline neurological status mNIS+7, 6-minute walk test, Norfolk QOL
Vitamin A Supplementation RDA dosing required Treatment plan documentation
Site of Care Infusion center Facility certification and administration plan

Essential Documentation Checklist

Before submitting your PA request, gather:

  • Insurance card and member ID
  • Complete genetic testing report confirming pathogenic TTR variant
  • Neurologist's comprehensive evaluation with ICD-10 codes
  • Baseline functional assessments (mNIS+7 score, 6-minute walk test)
  • Documentation of vitamin A supplementation plan
  • Prior therapy history (if applicable)
  • Infusion center certification

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Specialist Care

Who: Patient and neurologist
Timeline: 1-2 weeks
Ensure you have confirmed hATTR-PN via genetic testing showing a pathogenic TTR variant. Your neurologist should document baseline functional status using standardized assessments.

2. Contact Humana for PA Forms

Who: Clinic staff or patient
How: Call 1-800-555-2546 or access Humana's provider portal
Timeline: Same day
Request Onpattro-specific PA forms and confirm your plan's exact requirements.

3. Submit Complete PA Package

Who: Prescribing neurologist
How: Fax, online portal, or mail
Timeline: 2-3 business days to compile
Include all required documentation with a comprehensive medical necessity letter.

4. Await Humana's Decision

Timeline: Up to 14 days (standard) or 72 hours (expedited)
Humana will notify you and your prescriber in writing of their decision.

5. If Approved: Coordinate Infusion Services

Who: Patient and specialty pharmacy
Work with Humana's preferred specialty pharmacy network to schedule infusions and confirm coverage details.

6. If Denied: File Internal Appeal Immediately

Timeline: Must file within 65 days
Don't wait—begin the appeal process while exploring other options.

Clinician Corner: Medical Necessity Letter

Your medical necessity letter should address:

  1. Patient's specific diagnosis with ICD-10 codes (G62.9 for polyneuropathy)
  2. Genetic testing results confirming pathogenic TTR variant
  3. Functional assessment scores and disease progression
  4. Treatment goals and expected outcomes
  5. Safety monitoring plan including vitamin A supplementation
  6. Dosing rationale (0.3 mg/kg for <100 kg; 30 mg for ≥100 kg)

Key Clinical References:

Common Denial Reasons & Solutions

Denial Reason How to Fix It
No genetic confirmation Submit certified lab report showing pathogenic TTR variant
Missing specialist evaluation Obtain comprehensive neurologist assessment with functional scores
Incomplete functional assessment Provide baseline mNIS+7, 6MWT, Norfolk QOL scores
Lack of vitamin A plan Document RDA supplementation protocol
Site of care concerns Confirm infusion center certification and administration plan
Non-formulary status File formulary exception with medical necessity documentation

Appeals Process in Michigan

Internal Appeal (First Level)

Timeline: File within 65 days of denial
Decision: Within 7 days (expedited) or 30 days (standard)
How to file: Call 1-800-555-2546, online portal, or mail

External Review (Final Level)

If Humana upholds their denial, you have 127 days to request an external review through Michigan's Department of Insurance and Financial Services (DIFS).

Contact DIFS:

Tip: Michigan's external review process is binding on the insurer. If the independent medical reviewer overturns Humana's denial, they must cover your treatment.

Cost-Saving Strategies

Manufacturer Support Programs

Alnylam Assist Copay Program:

  • Eligibility: Commercial insurance only (Medicare patients ineligible)
  • Coverage: Reduces out-of-pocket costs
  • How to apply: Alnylam Assist website or provider Start Form

Patient Assistance Program (PAP):

  • Eligibility: Uninsured or functionally uninsured patients
  • Coverage: Free medication for qualified patients
  • Process: Alnylam Case Manager assessment via Start Form

Alternative Funding Sources

For Medicare patients ineligible for manufacturer copay assistance:

  • Independent 501(c)(3) foundations
  • State pharmaceutical assistance programs
  • Hospital charity care programs
  • Specialty pharmacy patient advocacy services

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Onpattro. Their platform analyzes denial letters and creates targeted, evidence-backed appeals that address payer-specific requirements and procedural details.

Pharmacy Network Optimization

Humana Specialty Pharmacy Benefits:

  • Home infusion services available
  • Coordination with infusion centers
  • Insurance verification and prior authorization support
  • Clinical monitoring and outcomes tracking

When to Escalate

Contact Michigan DIFS if:

  • Humana misses appeal deadlines
  • You suspect unfair claim practices
  • External review procedures aren't followed properly

Contact information:

  • DIFS Consumer Hotline: 877-999-6442
  • Online complaints: Michigan.gov/DIFS
  • Resources: "How to Appeal a Health Insurance Decision" brochure

Scripts & Templates

Calling Humana Script

"I need to request prior authorization for Onpattro (patisiran) for hereditary transthyretin amyloidosis. Can you send me the specific PA forms and tell me exactly what documentation you need? My member ID is [number] and my prescribing physician is Dr. [name]."

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for my patient's Onpattro PA denial. This patient has confirmed hATTR-PN with genetic testing and progressive functional decline. When can we schedule the clinical discussion?"

FAQ

How long does Humana's PA process take for Onpattro?
Standard decisions within 14 days; expedited reviews within 72 hours if medical urgency is documented.

What if Onpattro isn't on my formulary?
File a formulary exception request with medical necessity documentation. Humana covers non-formulary medications when medically necessary.

Can I get expedited appeals in Michigan?
Yes, both Humana internal appeals and DIFS external reviews offer expedited processing (72 hours) with physician documentation of medical urgency.

Does step therapy apply to Onpattro?
Requirements vary by plan. Some may require trials of supportive care or other treatments, while others recognize Onpattro as first-line for confirmed hATTR-PN.

What happens if I move out of Michigan?
Your appeal rights transfer, but deadlines and processes may differ. Contact your new state's insurance department for specific procedures.

How often do I need reauthorization?
Typically every 6-12 months, with functional assessments required to demonstrate stability or improvement.

Through strategic documentation and persistent advocacy, most patients with confirmed hATTR-PN can successfully obtain Onpattro coverage. Counterforce Health's platform can help streamline this process by automatically generating targeted appeals that address Humana's specific requirements and Michigan's procedural standards.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional help with complex appeals, visit Counterforce Health for specialized insurance advocacy services.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.