By Counterforce Health Team in Imbruvica (ibrutinib) —

Getting Imbruvica (Ibrutinib) Covered by Humana in Washington: Coding, Prior Authorization, and Appeals Guide

Answer Box: Getting Imbruvica (Ibrutinib) Covered by Humana in Washington

Humana Medicare Advantage requires prior authorization for Imbruvica (ibrutinib) with step therapy preferences for acalabrutinib or zanubrutinib first. To get approved: (1) Your oncologist submits a PA request via Humana's provider portal with proper ICD-10 codes (C91.10-C91.12 for CLL, C83.0- for SLL), clinical documentation, and medical necessity letter; (2) If denied, file internal appeal within 65 days; (3) Use Washington's external review process through the Office of the Insurance Commissioner if needed. Start by verifying your formulary tier and restrictions at humana.com/pharmacy/medicare-drug-list.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Imbruvica Coverage
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification with Humana Resources
  7. Quick Pre-Submission Audit Checklist
  8. Appeals Process in Washington
  9. Cost Support and Patient Resources
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Imbruvica (ibrutinib) is an oral BTK inhibitor typically covered under the pharmacy benefit for most Humana Medicare Advantage plans. However, understanding both pathways helps ensure proper billing and coverage.

Pharmacy Benefit (Most Common)

  • NDC-based billing using 11-digit National Drug Codes
  • Covered under Medicare Part D formulary
  • Subject to tier placement (typically Tier 5), prior authorization, and step therapy
  • Quantity dispensed in tablets, capsules, or mL for oral suspension

Medical Benefit (Less Common)

  • J-code billing using J8999 (unclassified oral chemotherapeutic agent)
  • May apply for "brown bag" or clinic-dispensed scenarios
  • Requires NDC number on claim along with J-code
  • Units calculated based on payer-specific definitions
Note: Always verify with Humana which benefit applies to your specific plan before submitting claims.

ICD-10 Mapping for Imbruvica Coverage

Proper ICD-10 coding is essential for Imbruvica prior authorization approval. Use the most specific codes available based on clinical documentation.

Primary ICD-10 Codes for FDA-Approved Indications

Condition ICD-10 Code Description Documentation Requirements
Chronic Lymphocytic Leukemia C91.10 CLL, not having achieved remission Pathology report, flow cytometry
C91.11 CLL, in remission Treatment response documentation
C91.12 CLL, in relapse Progression evidence, imaging
Small Lymphocytic Lymphoma C83.00-C83.09 SLL by anatomic site Biopsy results, staging studies
Waldenström Macroglobulinemia C88.0 Waldenström macroglobulinemia Bone marrow biopsy, IgM levels
Chronic GVHD D89.813 Graft-versus-host disease, chronic Post-transplant documentation

Supporting Documentation Language

When submitting prior authorization requests, include specific terminology that supports your ICD-10 coding:

  • For CLL/SLL: "Flow cytometry confirms CD19+, CD5+, CD23+ B-cell population"
  • For del(17p): "FISH analysis demonstrates 17p deletion"
  • For treatment-naive: "No prior systemic therapy for CLL"
  • For relapsed/refractory: "Progressive disease after [specific prior therapy]"

Product Coding: HCPCS, J-Codes, and NDC Numbers

NDC Numbers for Electronic Claims (11-digit format)

Tablets (28-count cartons):

  • 420 mg: 57962-0420-28
  • 280 mg: 57962-0280-28
  • 140 mg: 57962-0014-28

Capsules:

  • 140 mg (90-count): 57962-0140-09
  • 140 mg (120-count): 57962-0140-12
  • 70 mg (28-count): 57962-0070-28

Oral Suspension:

  • 70 mg/mL (108 mL): 57962-0007-12

HCPCS/J-Code for Medical Benefit

  • J8999 - Prescription drug, oral, chemotherapeutic, not otherwise specified
  • Always include the NDC number on the claim
  • Units calculated per payer instructions (typically 1 unit = 1 tablet/capsule or 1 mg)

Dosing Calculations

Example: 420 mg once daily, 30-day supply

  • Using 420 mg tablets: 1 tablet/day × 30 days = 30 tablets
  • NDC: 57962-0420-28
  • Pharmacy claim quantity: 30 tablets
  • If medical benefit: J8999 units = 30 (if unit = tablet) or 12,600 (if unit = mg)

Clean Prior Authorization Request Anatomy

A successful Humana prior authorization for Imbruvica should include these components:

Required Clinical Information

  1. Patient Demographics
    • Humana member ID
    • Date of birth
    • Prescribing physician NPI
  2. Diagnosis Documentation
    • Primary ICD-10 code with specificity
    • Pathology/flow cytometry reports
    • Staging information when applicable
  3. Treatment History
    • Prior therapies tried and failed
    • Dates of treatment and duration
    • Reason for discontinuation (progression, toxicity)
  4. Medical Necessity Justification
    • FDA-approved indication
    • NCCN guideline support
    • Why preferred alternatives aren't suitable

Step Therapy Considerations

Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and crafting targeted appeals. Their platform identifies specific denial reasons and provides evidence-backed rebuttals aligned to each payer's policies.

Humana typically requires trial of preferred BTK inhibitors before approving Imbruvica:

  • Preferred agents: Acalabrutinib (Calquence), Zanubrutinib (Brukinsa)
  • Override criteria: Prior failure, intolerance, or contraindication to preferred agents
  • Documentation needed: Treatment records showing inadequate response or adverse effects

Frequent Coding and Billing Pitfalls

Common Mistakes to Avoid

  1. Incorrect NDC Format
    • ❌ Using 10-digit NDC (57962-420-28)
    • ✅ Using 11-digit NDC (57962-0420-28)
  2. Unit Conversion Errors
    • ❌ Billing 1 unit for 420 mg when payer defines unit as 1 mg
    • ✅ Billing 420 units when unit = mg, or 1 unit when unit = tablet
  3. Missing Diagnosis Specificity
    • ❌ Using C91.1 (CLL, unspecified)
    • ✅ Using C91.10, C91.11, or C91.12 based on remission status
  4. Inadequate Prior Authorization Documentation
    • ❌ Generic "patient needs Imbruvica for cancer"
    • ✅ Specific indication, prior treatments, and guideline support

Documentation Red Flags

  • Vague diagnosis codes without supporting pathology
  • Missing treatment history for step therapy requirements
  • Lack of medical necessity justification
  • Incorrect dosing calculations or NDC selection

Verification with Humana Resources

Before submitting any prior authorization or claim, verify current requirements through official Humana channels:

Key Verification Steps

  1. Check Formulary Status
  2. Review Coverage Policies
  3. Confirm Prior Authorization Process
    • Provider portal: mcp.humana.com
    • Phone: Contact number on member ID card
    • Verify required forms and submission method

Quick Pre-Submission Audit Checklist

Use this checklist before submitting your Imbruvica prior authorization:

Clinical Documentation ✓

  • Specific ICD-10 code (C91.10-12, C83.0-, etc.)
  • Pathology/flow cytometry reports attached
  • Complete treatment history documented
  • Medical necessity letter from oncologist

Coding Accuracy ✓

  • Correct 11-digit NDC number
  • Proper unit calculations verified
  • J-code (J8999) included if medical benefit
  • Dosing matches FDA labeling

Payer Requirements ✓

  • Step therapy documentation if applicable
  • Formulary status confirmed
  • Prior authorization form completed
  • All required attachments included

Appeals Process in Washington

If Humana denies your Imbruvica prior authorization, Washington residents have robust appeal rights through both federal Medicare processes and state protections.

Internal Appeals (Humana)

Level 1: Organization Determination Appeal

  • Timeline: 65 days from denial notice to file
  • Decision time: 30 days (standard) or 72 hours (expedited)
  • How to file: Humana member portal or phone
  • Required: Medical necessity documentation, prescriber letter

External Review (Washington State)

Washington's Office of the Insurance Commissioner provides additional consumer protections:

  • Contact: Washington SHIBA at 1-800-562-6900
  • Process: Independent Review Organization (IRO) evaluation
  • Timeline: 180 days from final internal denial to request external review
  • Outcome: Binding decision on insurer if overturned
From our advocates: We've seen many Washington patients successfully overturn Imbruvica denials by providing comprehensive treatment failure documentation and emphasizing urgency for progressive disease. The key is thorough clinical justification and meeting all deadlines.

When to Request Expedited Review

Request expedited appeals when:

  • Disease is rapidly progressing
  • Delay could seriously harm health
  • Current treatment is failing or causing severe toxicity

Cost Support and Patient Resources

Manufacturer Support Programs

AbbVie Patient Assistance:

  • Income-based free drug program
  • Eligibility: Household income ≤400% federal poverty level
  • Application: abbvie.com/patients

Medicare-Specific Support

Since Medicare patients can't use copay cards, alternative options include:

  • Patient Advocate Foundation
  • CancerCare Co-Payment Assistance
  • Leukemia & Lymphoma Society financial aid

2025 Medicare Part D Changes

Medicare's negotiated price for Imbruvica drops to $9,319 for a 30-day supply in 2026, with the $2,000 annual out-of-pocket cap providing significant savings for current patients.

FAQ

How long does Humana prior authorization take for Imbruvica in Washington? Standard decisions take up to 30 days for pre-service requests. Expedited reviews are completed within 72 hours when medical urgency is documented.

What if Imbruvica is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate or contraindicated.

Does step therapy apply if I've already failed BTK inhibitors outside Washington? Yes, but prior treatment failure documentation from any location can satisfy step therapy requirements. Provide complete treatment records.

Can I request an expedited appeal for Imbruvica denial? Yes, if delay could seriously harm your health or ability to function. Your oncologist must document medical urgency in the appeal request.

What's the difference between Medicare appeals and Washington state appeals? Medicare Advantage follows federal appeal levels (organization determination, IRE, ALJ). Washington's IRO process provides additional consumer protections for certain disputes.

How do I prove medical necessity for off-label Imbruvica use? Include peer-reviewed literature, NCCN compendium listings, and detailed clinical rationale from your oncologist explaining why standard treatments aren't appropriate.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. For personalized assistance with complex prior authorizations and appeals, Counterforce Health provides evidence-based support to help patients and providers navigate insurance requirements effectively. Always consult with your healthcare provider and insurance plan for specific coverage questions.

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