By Counterforce Health Team in Trikafta (elexacaftor/tezacaftor/ivacaftor) —

Get Trikafta Covered by Humana in Florida: Complete Prior Authorization Guide with Forms and Appeals

Quick Answer: Getting Trikafta Covered by Humana in Florida

Trikafta requires prior authorization from Humana Medicare Advantage/Part D plans in Florida. Submit the Request for Medicare Prescription Drug Coverage Determination form with CFTR genotype results, liver function tests, and a medical necessity letter from your CF specialist. Fax to 877-486-2621 or submit via Humana's provider portal. Standard approval takes 7 days; expedited requests get 72-hour decisions. If denied, you have 65 days to file an internal appeal, followed by federal external review if needed.

Start today: Call your CF center to gather genetic testing results and recent lab work, then contact Humana at 800-867-6601 to verify your plan's formulary status.

Table of Contents

  1. Verify Your Plan and Formulary Status
  2. Required Documentation for Trikafta PA
  3. Submission Forms and Portals
  4. CenterWell Specialty Pharmacy Setup
  5. Appeals Process in Florida
  6. Support Lines and Contacts
  7. Common Denial Reasons and Solutions
  8. Cost Assistance Programs
  9. FAQ

Verify Your Plan and Formulary Status

Before starting your prior authorization, confirm Trikafta's status on your specific Humana plan. Most Humana Medicare Advantage and Part D plans require PA for this high-cost specialty drug (~$300,000+ annually).

Check your coverage:

Note: Trikafta is typically placed on specialty tiers requiring prior authorization, step therapy documentation, and specialty pharmacy dispensing.

Required Documentation for Trikafta PA

Humana requires comprehensive documentation proving medical necessity for cystic fibrosis patients. Gather these documents before submitting your PA request:

Essential Requirements

Document Type Details Timeline
CFTR Genotype Report Lab results confirming F508del or other responsive mutations Any time (permanent)
Liver Function Tests ALT, AST, total bilirubin Within 90 days
Pulmonary Function Tests FEV1, FVC for patients age 6+ Within 6 months
Medical Necessity Letter From CF specialist (pulmonologist preferred) Current

Medical Necessity Letter Checklist

Your CF specialist's letter should include:

  • Diagnosis: ICD-10 codes E84.0-E84.9 (cystic fibrosis)
  • CFTR mutation details: Specific genotype requiring triple therapy
  • Clinical status: Current symptoms, lung function, nutritional status
  • Treatment goals: Expected improvements in lung function/quality of life
  • Monitoring plan: Liver function testing schedule
  • Prescriber credentials: CF center affiliation, board certification

Submission Forms and Portals

Primary Submission Methods

1. Online Portal (Fastest)

2. Fax Submission

  • Prior Authorization fax: 877-486-2621
  • Use the Request for Medicare Prescription Drug Coverage Determination form
  • Available in English and Spanish

3. Phone Submission

  • Call 800-867-6601 for expedited Part D requests
  • Follow up with written documentation if requested

Timeline Expectations

Request Type Response Time When to Use
Standard PA 7 calendar days Routine requests
Expedited PA 72 hours Urgent medical need

CenterWell Specialty Pharmacy Setup

Humana requires Trikafta to be dispensed through their specialty pharmacy network, primarily CenterWell Specialty Pharmacy.

Enrollment Steps

For Patients:

  1. Call 800-486-2668 (Mon-Fri 8am-11pm ET, Sat 8am-6:30pm ET)
  2. Register online at CenterWell Specialty or use MyHumana login
  3. Provide Florida delivery address and insurance information
  4. Complete financial assistance screening

For Prescribers:

  1. E-prescribe to "CenterWell Specialty Pharmacy"
  2. Fax prescriptions to 877-405-7940
  3. Include PA approval number once obtained
From our advocates: We've seen faster approvals when patients proactively enroll with CenterWell while their PA is pending. This eliminates delays once approval comes through, and the pharmacy can help coordinate financial assistance programs during the waiting period.

Appeals Process in Florida

If Humana denies your Trikafta request, Florida residents follow the federal Medicare appeals process, not state-specific procedures.

Level 1: Internal Appeal (Redetermination)

Timeline: 65 days from denial notice Form: Request for Redetermination of Medicare Prescription Drug Denial Response time: 7 calendar days

Submit via:

  • Same methods as original PA (fax 877-486-2621)
  • Include additional clinical evidence
  • Request peer-to-peer review with Humana medical director

Level 2: External Review

If internal appeal fails, Florida uses the HHS-Administered Federal External Review Process through MAXIMUS.

Contact Information:

Timeline: 4 months from final internal denial Cost: Free to consumers Response: 45 days (standard) or 72 hours (expedited)

Support Lines and Contacts

Humana Member Services

  • General inquiries: Number on your insurance card
  • Pharmacy questions: 800-379-0092
  • Part D appeals: 800-867-6601

Provider Support

  • Clinical questions: 800-555-2546 (Mon-Fri 8am-8pm ET)
  • CenterWell Specialty: 800-486-2668

Florida State Resources

Note: For Medicare plans, state insurance departments have limited authority. Use federal appeals processes for coverage disputes.

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Missing CFTR genotype Submit genetic testing results Lab report showing F508del or responsive mutations
Incomplete lab work Provide recent liver function tests ALT, AST, bilirubin within 90 days
Non-formulary status Request formulary exception Medical necessity letter comparing to alternatives
Quantity limits exceeded Justify dosing requirements Weight-based calculations, specialist letter

Cost Assistance Programs

Even with insurance approval, Trikafta can have significant out-of-pocket costs. Explore these options:

Manufacturer Support

  • Vertex Compass: Patient assistance program
  • CF Foundation Compass: Financial navigation services
  • Copay assistance: May reduce monthly costs significantly

Additional Resources

  • Medicare Extra Help: Low-income subsidy program
  • State pharmaceutical assistance: Limited programs in Florida
  • CF Foundation grants: Emergency financial assistance

When working with insurance appeals, Counterforce Health helps patients and clinicians turn coverage denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

FAQ

How long does Humana PA take for Trikafta in Florida? Standard requests take 7 calendar days; expedited requests get 72-hour decisions when urgent medical need is documented.

What if Trikafta isn't on my Humana formulary? Request a formulary exception using the same coverage determination form, emphasizing medical necessity and lack of effective alternatives.

Can I get expedited approval? Yes, if standard timelines would jeopardize your health. Check the "expedited" box on forms and provide supporting clinical documentation.

Do I need step therapy documentation? Most Humana plans require documentation of prior CFTR modulator trials or contraindications to alternatives like Symdeko or Kalydeco.

What happens if my appeal is denied? You can escalate to federal external review through MAXIMUS (free) or request an Administrative Law Judge hearing if the controversy exceeds $190.

Does Florida have special CF coverage laws? Florida follows federal Medicare standards for coverage. State-specific protections don't apply to Medicare Advantage plans.

How often do I need to renew PA? Most approvals last 6-12 months. Submit renewal requests 30-60 days before expiration to avoid therapy gaps.

Can I use retail pharmacies for Trikafta? Humana typically requires specialty pharmacy dispensing through CenterWell, though some plans allow limited retail fills.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always verify current requirements with your insurance provider and consult your healthcare team for medical decisions. For complex appeals, consider working with Counterforce Health or other patient advocacy services that specialize in insurance coverage challenges.

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