By Counterforce Health Team in Revcovi (elapegademase) —

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

Quick Answer: Humana Coverage for Revcovi in Washington

Humana covers Revcovi (elapegademase) for ADA-SCID under Medicare Advantage and Part D plans, but requires prior authorization with confirmed diagnosis and specialist documentation. In Washington, you have 65 days to appeal denials, with state external review available for medical benefits. First step today: Contact your immunologist to gather ADA enzyme results (<1% normal) and genetic testing confirming biallelic ADA mutations, then submit PA via Humana's member portal with medical necessity letter.

Table of Contents

Plan Types & Coverage Implications

Humana offers several plan types in Washington, each with different coverage rules for Revcovi:

Medicare Advantage (Part C): Covers Revcovi as a specialty drug benefit with prior authorization. Network restrictions apply - you'll need to use Humana's preferred specialty pharmacies.

Medicare Part D: Standalone prescription drug plans that cover Revcovi on the specialty tier. Appeals follow federal Medicare timelines (65 days for initial appeal).

Commercial Plans: Limited availability in Washington. Coverage varies by employer group and follows state insurance regulations for appeals.

Note: Most Humana members in Washington have Medicare Advantage plans. Verify your specific plan type by calling Member Services at 1-800-281-6918.

Formulary Status & Tier Placement

Plan Type Formulary Status Typical Tier Prior Auth Required
Medicare Advantage Covered Specialty (Tier 5) Yes
Part D Covered Specialty (Tier 5) Yes
Commercial Varies Specialty Yes

Revcovi is typically placed on the highest cost-sharing tier due to its specialized nature and high cost (approximately $11,851 per 1.5 mL vial). However, Humana's formulary may offer exceptions for medical necessity.

Prior Authorization Requirements

Essential Documentation

Confirmed ADA-SCID Diagnosis:

  • ADA enzyme activity <1% of normal in red blood cells
  • Genetic testing showing biallelic pathogenic ADA gene variants
  • Clinical SCID presentation (recurrent infections, failure to thrive)
  • ICD-10 code D81.3 (adenosine deaminase deficiency)

Specialist Evaluation Required:

  • Consultation from pediatric immunologist or geneticist
  • Medical necessity letter explaining why enzyme therapy is needed
  • Documentation of failed alternatives or contraindications to stem cell transplant
  • Treatment monitoring plan

Dosing and Administration Requirements

Humana's coverage policies typically require:

  • Standard dosing: 0.4 mg/kg weekly for Adagen-naïve patients
  • Divided doses: Usually given as 0.2 mg/kg twice weekly via intramuscular injection
  • Monitoring schedule: Trough ADA levels every 2 weeks initially, then monthly
  • Site of care: Home administration possible after training

Specialty Pharmacy Network

Humana primarily uses CenterWell Specialty Pharmacy for Revcovi distribution:

  • Contact: 1-800-486-2668 (Mon-Fri 8am-11pm ET)
  • Fax: 1-877-405-7940
  • Services: Nationwide mail delivery, clinical support, financial assistance coordination

Alternative Options in Washington: Use Humana's pharmacy finder to locate in-network specialty pharmacies in your area. Seattle and Spokane have additional specialty pharmacy options.

Cost-Share Dynamics

Typical Costs (Educational Only)

  • Medicare Advantage: $0-$500+ monthly depending on plan
  • Part D: Subject to specialty tier coinsurance (25-33% typical)
  • Commercial: Varies widely by employer plan design

Financial Assistance

  • Manufacturer support: Contact Revcovi Total Care for patient assistance programs
  • Foundation grants: NORD and other rare disease foundations may help
  • Medicare patients: Cannot use manufacturer copay cards due to anti-kickback laws
Important: These are general ranges. Contact Humana Member Services for your specific cost-sharing details.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Insurance card and member ID
    • ADA enzyme results and genetic testing
    • Specialist consultation notes
    • Prior therapy history
  2. Complete Prior Authorization Form (Prescriber)
    • Submit via Humana provider portal
    • Include medical necessity letter with clinical rationale
    • Attach all supporting lab results and imaging
  3. Submit to CenterWell Specialty (Pharmacy)
    • Forward prescription and PA approval
    • Coordinate delivery and administration training
    • Set up monitoring schedule
  4. Track Decision Timeline (Patient)
    • Standard PA: 7-30 days
    • Expedited: 24-72 hours if urgency documented
    • Follow up if no response within expected timeframe

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • Patient demographics and clinical history
  • Confirmed ADA-SCID diagnosis with supporting lab values
  • Failed alternatives or contraindications to other treatments
  • Expected clinical outcomes and monitoring plan
  • Citations to FDA labeling and treatment guidelines

Appeals Process in Washington

Washington provides robust patient protections for insurance denials, with both federal Medicare appeals and state-level external review options.

Medicare Part D Appeals (Most Common)

Level 1 - Redetermination by Humana:

  • Deadline: 65 days from denial notice
  • Timeline: 7 days standard, 24 hours expedited
  • How to file: Humana member portal or written request

Level 2 - Independent Review Entity (IRE):

  • Automatic escalation if Humana upholds denial
  • Review by CMS-contracted independent organization
  • Timeline: 7 days standard, 72 hours expedited

Washington State External Review

For medical benefits (infusion coverage), Washington offers additional protection:

Independent Review Organization (IRO):

  • Available after completing Humana's internal appeals
  • Deadline: 180 days from final internal denial
  • Contact: Washington Office of Insurance Commissioner at 1-800-562-6900
  • Process: State assigns independent medical experts to review case
  • Timeline: 30 days standard, 72 hours expedited
  • Result: Binding decision on the insurer
Tip: The Washington OIC provides free appeal assistance and template letters for common scenarios.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient diagnosis Submit complete genetic testing Biallelic ADA mutations, enzyme activity <1%
Lack of specialist oversight Get immunologist consultation Specialty clinic letter with treatment plan
Step therapy not met Document failed alternatives Prior therapy records, contraindication notes
Dosing above limits Justify medical necessity Weight-based calculations, monitoring data
Non-formulary status Request formulary exception Comparative effectiveness data

From Our Advocates

"We've seen Washington patients successfully overturn Revcovi denials by emphasizing the life-threatening nature of untreated ADA-SCID and providing detailed genetic testing results. The key is having your immunologist clearly explain why alternatives like stem cell transplant aren't suitable for your specific case. State external review has been particularly effective when plans incorrectly classify enzyme therapy as experimental."

When to Escalate

Contact the Washington Office of Insurance Commissioner if:

  • Humana doesn't respond within required timeframes
  • You need help understanding your appeal rights
  • The denial seems to contradict medical evidence

Washington OIC Contact:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Services: Free consumer assistance, appeal guidance, complaint filing

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to the insurer's own rules, pulling the right citations and clinical facts to strengthen your case.

FAQ

How long does Humana prior authorization take in Washington? Standard PA decisions take 7-30 days. Expedited reviews (when delay could harm health) are decided within 24-72 hours.

What if Revcovi is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Emphasize that Revcovi is the only FDA-approved enzyme therapy for ADA-SCID.

Can I request an expedited appeal? Yes, if your doctor documents that waiting could seriously jeopardize your health. This is common for ADA-SCID patients at risk of severe infections.

Does step therapy apply if I've tried treatments outside Washington? Yes, document all prior therapies regardless of where they were tried. Include medical records showing why alternatives failed or were unsuitable.

What's the difference between Medicare appeals and Washington state external review? Medicare appeals apply to Part D drug coverage and follow federal timelines. Washington's external review applies to medical benefits and provides additional patient protections.

How much will Revcovi cost with Humana coverage? Costs vary by plan type and tier placement. Contact Member Services at 1-800-281-6918 for your specific cost-sharing details.

Can I use manufacturer copay assistance? Medicare patients cannot use copay cards due to federal anti-kickback laws. Commercial plan patients may be eligible - check with Revcovi Total Care.

What happens if my appeal is denied? For Part D denials, your case automatically moves to independent review. For medical benefits, you can request Washington state external review through the Insurance Commissioner.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and contact Humana directly for the most current coverage information. For personalized help with complex appeals, consider working with Counterforce Health or other patient advocacy services.

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