By Counterforce Health Team in Revcovi (elapegademase) —

Getting Revcovi (Elapegademase) Covered by Humana in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Fast Track to Revcovi Coverage with Humana in Texas

Getting Revcovi (elapegademase) covered by Humana requires prior authorization with documented ADA-SCID diagnosis and specialist oversight. Submit through Humana's provider portal with ADA enzyme testing (<1% normal activity) or genetic confirmation, plus a medical necessity letter from an immunologist. If denied, you have 65 days to appeal internally, then can request Texas external review within 4 months. Start today by gathering your diagnostic labs and asking your specialist to initiate the PA request through Humana's pharmacy coverage system.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Humana plans Humana Pharmacy Policies
ADA-SCID Diagnosis Enzyme activity <1% normal OR genetic testing Your immunologist's lab reports
Specialist Prescriber Immunologist, hematologist/oncologist, or ADA-SCID expert Provider directory or referral
Medical Necessity Letter Detailed clinical rationale required Template from prescriber
Maximum Dose 0.4 mg/kg weekly (IM/SC) FDA Label
Appeals Deadline 65 days from denial notice Humana denial letter

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation

Who: You and your immunologist
What: Gather ADA enzyme activity results showing <1% of normal levels OR molecular genetic testing confirming bi-allelic ADA gene variants
Timeline: Before PA submission
Source: Humana's elapegademase policy criteria

2. Schedule Specialist Consultation

Who: Your primary care doctor or you directly
What: Referral to immunologist, hematologist/oncologist, or physician specializing in ADA-SCID
Timeline: 2-4 weeks for appointment
Note: Humana requires specialist oversight for Revcovi prescriptions

3. Request Medical Necessity Letter

Who: Your specialist
What: Comprehensive letter addressing why Revcovi is medically necessary, including failed/contraindicated alternatives like bone marrow transplant
Timeline: 1-2 weeks after consultation

4. Submit Prior Authorization

Who: Your prescriber's office
What: Complete PA request through Humana's provider portal or fax to designated number
Timeline: Humana has 7 days for standard decisions
Link: Humana Provider Portal

5. Enroll in Chiesi Total Care

Who: You or your prescriber
What: Complete Revcovi enrollment forms for specialty pharmacy dispensing
Timeline: Concurrent with PA submission
Link: Chiesi Total Care enrollment

Clinician Corner: Medical Necessity Letter Checklist

Your specialist's letter should include:Confirmed ADA-SCID diagnosis with specific lab valuesClinical history of recurrent infections or immune dysfunctionWhy curative treatments (HSCT, gene therapy) are unsuitable or have failedExpected clinical benefits from enzyme replacement therapyPlanned monitoring and response assessmentReference to FDA approval for ADA-SCID indication

Understanding Revcovi Costs and Your Options

Revcovi carries a significant cost burden—approximately $11,851 for a 1.5 mL vial at cash prices, though your actual cost depends on dosing, insurance coverage, and assistance programs.

Humana Coverage Tiers

Most Humana Medicare Advantage plans place Revcovi on specialty tier with higher cost-sharing. Your exact copay or coinsurance depends on your specific plan's benefit design.

Cost-Saving Strategies

  1. Manufacturer copay assistance (commercial insurance only)
  2. Patient assistance programs for uninsured/underinsured patients
  3. Foundation grants through NORD and rare disease organizations
  4. Formulary tier exceptions if placed on non-preferred tier

Benefit Investigation: What to Ask Humana

Before starting treatment, call Humana Member Services with these specific questions:

Coverage Questions:

  • "Is Revcovi (elapegademase) covered on my plan's formulary?"
  • "What tier is it placed on and what's my cost-sharing?"
  • "Are there quantity limits or site-of-care restrictions?"

Prior Authorization Questions:

  • "What documentation is required for PA approval?"
  • "How long does the PA process typically take?"
  • "Can I request expedited review if medically urgent?"

Appeals Information:

  • "What are my appeal rights if the PA is denied?"
  • "What's the deadline for filing an internal appeal?"
  • "How do I access external review in Texas?"

Record the representative's name, date, and reference number for your call.

Copay Cards and Patient Assistance Programs

Commercial Insurance Patients

If you have commercial (employer-sponsored) insurance, you may qualify for Revcovi's copay assistance program through Chiesi Total Care. This can reduce your out-of-pocket costs to as little as $0 per prescription.

Eligibility Requirements:

  • Must have commercial insurance (not Medicare/Medicaid)
  • Valid prescription for FDA-approved ADA-SCID indication
  • U.S. residency and licensed prescriber
  • Enrollment in Chiesi Total Care program

Uninsured or Underinsured Patients

The Patient Assistance Program (PAP) may provide free medication for those who meet financial need criteria and lack adequate insurance coverage.

Texas-Specific Resources

  • NORD RareCare Programs: Financial assistance for rare disease patients including medication copays, diagnostic testing, and travel expenses. Call 800-999-6673 or apply through their patient assistance portal.
  • My Good Days: Texas-focused organization providing copay assistance and medication access support for chronic and rare diseases.

Appeals Process for Texas Residents

If Humana denies your Revcovi prior authorization, Texas law provides strong appeal rights:

Internal Appeal (Level 1)

Deadline: 65 days from denial notice
Timeline: Humana has 7 days for standard appeals, 72 hours for expedited
How to file: Online through member portal, fax to 877-486-2621, or mail
Required: Completed coverage determination request form

External Review (Level 2)

Deadline: 4 months from final internal denial
Timeline: 20 days for standard review, 5 days for urgent cases
Process: Texas Department of Insurance coordinates Independent Review Organization (IRO)
Cost: Free to you (insurer pays IRO fees)
Contact: TDI IRO information line at 1-866-554-4926

Note: Self-funded employer plans follow federal ERISA rules, not Texas external review. Medicare appeals use the federal Medicare appeals process.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn
"Diagnosis not confirmed" Submit ADA enzyme activity results <1% normal OR genetic testing showing bi-allelic ADA variants
"Not medically necessary" Medical necessity letter explaining why HSCT/gene therapy unsuitable; document infection history
"Experimental/investigational" Cite FDA approval (October 2018) and include FDA label excerpt
"Formulary alternative available" Explain that Revcovi is the only FDA-approved ERT for ADA-SCID in the U.S.
"Quantity/dose exceeded" Provide weight-based dosing calculation and FDA-approved maximum (0.4 mg/kg weekly)

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned to each plan's specific policies.

Specialty Pharmacy Requirements

Humana requires Revcovi to be dispensed through their preferred specialty pharmacy network. Your prescriber must:

  1. Coordinate with Humana-approved specialty pharmacies for fulfillment
  2. Provide complete documentation including diagnosis, dosing rationale, and monitoring plan
  3. Submit renewal requests with evidence of clinical benefit for continued coverage

The Chiesi Total Care program helps coordinate between prescribers, specialty pharmacies, and insurance for seamless access.

From Our Advocates

Many families find success by having their specialist submit the PA request directly rather than going through the primary care office. Immunologists familiar with ADA-SCID typically have template letters and know exactly what documentation Humana requires, which can speed up the approval process significantly.

FAQ: Revcovi Coverage Questions

How long does Humana prior authorization take in Texas?
Standard PA decisions are made within 7 calendar days. Expedited requests (when delay would jeopardize health) are decided within 72 hours.

What if Revcovi is non-formulary on my plan?
You can request a formulary exception with medical necessity documentation. If approved, it may be placed at a higher cost-sharing tier.

Can I get an expedited appeal if denied?
Yes, if a delay would seriously jeopardize your health or ability to regain maximum function. Your doctor must support the expedited request.

Does step therapy apply to Revcovi?
Generally no, since Revcovi is the only FDA-approved enzyme replacement therapy for ADA-SCID. However, Humana may require documentation of why curative treatments aren't appropriate.

What counts as medical necessity for Revcovi?
Confirmed ADA-SCID diagnosis with documented enzyme deficiency or genetic confirmation, plus clinical evidence that curative treatments (bone marrow transplant, gene therapy) are contraindicated or have failed.

How much will I pay out-of-pocket?
This depends on your plan's specialty drug tier and benefit design. Commercial insurance patients may qualify for copay assistance programs that reduce costs to $0.

What if I'm on Medicare?
Medicare patients cannot use manufacturer copay cards due to federal anti-kickback laws, but may qualify for patient assistance programs or foundation grants based on financial need.

Can I appeal to the state if Humana denies coverage?
Yes, Texas residents can request external review through an Independent Review Organization after exhausting internal appeals. The IRO's decision is binding on the insurer.

Renewal and Long-Term Planning

Revcovi authorizations typically cover 12 months, requiring annual renewal with documentation of:

  • Continued clinical benefit (improved immune function, reduced infections)
  • Ongoing medical necessity
  • Updated dosing based on weight changes
  • Specialist oversight and monitoring plan

Plan ahead by scheduling renewal requests 30-60 days before expiration to avoid treatment interruptions.

When to Get Additional Help

Contact these resources if you need extra support:

  • Texas Department of Insurance: 1-800-252-3439 for insurance complaints and appeal guidance
  • Office of Public Insurance Counsel (OPIC): 1-877-611-6742 for consumer assistance
  • Disability Rights Texas: Advocacy for Medicaid and insurance appeals
  • Counterforce Health: Specialized appeal assistance for complex denials

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage decisions depend on your specific insurance plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For official Texas insurance regulations and appeal procedures, visit the Texas Department of Insurance website.

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