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

Getting Trikafta Covered by Humana in Pennsylvania: Prior Authorization, Appeals, and Coding Guide

Answer Box: Fast Track to Trikafta Coverage

Trikafta requires prior authorization from Humana Medicare in Pennsylvania. Submit CFTR genotype documentation (F508del or other responsive mutations), current liver function tests, and ICD-10 code E84.0-E84.9 for cystic fibrosis. Humana decides within 7 days for standard requests, 72 hours for expedited. If denied, appeal within 65 days using Medicare's federal process—Pennsylvania's state external review doesn't apply to Medicare plans. Start gathering documentation 60-90 days before any renewal expires.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit

Trikafta (elexacaftor/tezacaftor/ivacaftor) is covered under Humana's Medicare Part D pharmacy benefit, not the medical benefit (Part B). This distinction is crucial for proper billing and authorization.

Pharmacy Benefit (Part D):

  • Billed using NDC (National Drug Code)
  • Requires prior authorization through Humana's pharmacy team
  • Filled at specialty pharmacies
  • Renewed every 6-12 months

Medical Benefit (Part B):

  • Would use HCPCS J-codes (not applicable for oral Trikafta)
  • Only covers limited oral medications (mainly anticancer drugs)
  • Trikafta doesn't qualify for Part B coverage in outpatient settings
Note: If billing to medical for any reason, use J8499 (prescription drug, oral, non-chemotherapeutic, NOS) with NDC, but expect denials.

ICD-10 Mapping for Cystic Fibrosis

Choose the most specific ICD-10 code based on your patient's primary CF manifestations:

ICD-10 Code Description When to Use
E84.0 Cystic fibrosis with pulmonary manifestations Most common; use for patients with lung involvement
E84.1 Cystic fibrosis with intestinal manifestations Primary GI symptoms (pancreatic insufficiency, DIOS)
E84.8 Cystic fibrosis with other manifestations Multiple organ involvement or atypical presentations
E84.9 Cystic fibrosis, unspecified Use only when specific manifestations aren't documented

Documentation Support: Include phrases like "chronic pulmonary infection," "pancreatic insufficiency," "CFTR F508del mutation," and "progressive lung disease" in clinical notes to support your chosen code.

Product Coding: NDC, HCPCS, and Billing

NDC Requirements:

  • Trikafta tablets: NDC 66794-015-28 (28-count bottle)
  • Trikafta granules: NDC 66794-016-56 (56 packets)
  • Always include the 11-digit NDC on pharmacy claims

Quantity and Units:

  • Standard dosing: 2 tablets AM, 1 tablet PM (3 tablets daily)
  • 28-day supply = 84 tablets
  • Granules: 2 packets AM, 1 packet PM for patients unable to swallow tablets

HCPCS Considerations: If billing to medical (rare), use J8499 with appropriate NDC. However, this will likely be denied as Trikafta doesn't meet Part B oral drug criteria.

Clean Request Anatomy

A complete Humana prior authorization request includes:

Required Clinical Documentation

  1. CFTR Genotype Report: Laboratory confirmation of F508del or other responsive mutations
  2. Current Labs: Liver function tests (ALT, AST, bilirubin) within 90 days
  3. Pulmonary Function Tests: Required for patients age 6 and older
  4. Medical Necessity Letter: From CF specialist detailing:
    • Confirmed CF diagnosis with ICD-10 code
    • Specific CFTR mutations
    • Clinical status and treatment goals
    • Monitoring plan for liver toxicity

Submission Details

  • Portal: Humana Provider Portal
  • Fax: 877-486-2621
  • Phone: 800-555-CLIN (2546), Monday-Friday, 8 a.m.-8 p.m.
  • Timeline: 7 days standard, 72 hours expedited
  • Renewal: Submit 2-4 weeks before expiration

Common Coding Pitfalls

Frequent Mistakes and Solutions

Pitfall Problem Solution
Missing genotype No CFTR mutation documentation Always attach genetic lab report
Outdated labs Liver function tests >90 days old Update labs before each submission
Wrong benefit Billing to Part B instead of Part D Use pharmacy benefit pathway
Generic diagnosis Using E84.9 when specific code applies Choose most specific E84.x code
Late renewal Submitting after authorization expires Set calendar reminders 60-90 days early

Unit Conversion Errors

  • Don't confuse tablet count with day supply
  • Standard 28-day supply = 84 tablets (not 28)
  • Granules and tablets have different NDCs

Verification with Humana

Before submitting your prior authorization:

  1. Check Formulary Status: Verify Trikafta is on your patient's specific Humana Part D formulary
  2. Confirm Specialty Pharmacy: Ensure prescription will be filled at an in-network specialty pharmacy
  3. Review Prior Authorization List: Check Humana's current PA requirements
  4. Validate Submission Method: Confirm current portal URL or fax number hasn't changed
Tip: Call Humana Provider Services at 800-555-CLIN to verify current requirements before submitting complex cases.

Appeals Process in Pennsylvania

If Humana denies your Trikafta prior authorization, use Medicare's federal appeals process—Pennsylvania's state external review program doesn't apply to Medicare plans.

Internal Appeals Timeline

  • First Level (Redetermination): 60 days from denial date
  • Second Level (Reconsideration): 60 days from redetermination denial
  • Third Level: Medicare Administrative Law Judge hearing

Key Steps

  1. Request Peer-to-Peer: Ask for physician-to-physician review with Humana's medical director
  2. Submit Additional Evidence: Include updated labs, clinical notes, or literature support
  3. Consider Expedited Process: Available for urgent medical situations
  4. Document Everything: Keep copies of all correspondence and track deadlines
Important: Pennsylvania residents cannot use the state's Independent External Review Program for Medicare Advantage appeals. Stick to the federal Medicare process.

Pre-Submission Checklist

Before submitting your Trikafta prior authorization:

Clinical Documentation:

  • CFTR genotype report (F508del or responsive mutation)
  • Current liver function tests (within 90 days)
  • Pulmonary function tests (age 6+)
  • Medical necessity letter from CF specialist
  • Most recent clinic notes

Administrative Details:

  • Correct ICD-10 code (E84.0-E84.9)
  • Proper NDC for tablets or granules
  • Patient demographics and insurance information
  • Prescriber NPI and contact information

Submission Logistics:

  • Using correct Humana submission method
  • All forms signed and dated
  • Legible copies of all documents
  • Tracking number or confirmation receipt

From our advocates: "We've seen the most success when providers submit Trikafta renewals 30-45 days early with a comprehensive packet including recent PFTs and a detailed letter explaining the patient's clinical response. This proactive approach prevents coverage gaps and gives time to address any questions Humana might have."

FAQ

How long does Humana take to approve Trikafta prior authorization? Standard requests: 7 calendar days. Expedited requests: 72 hours when clinical urgency is documented.

What if Trikafta isn't on my Humana formulary? Request a formulary exception with medical necessity documentation. Include peer-reviewed evidence supporting Trikafta's superiority over formulary alternatives.

Can I use Pennsylvania's external review for Humana Medicare denials? No. Pennsylvania's Independent External Review Program only applies to commercial insurance. Medicare appeals follow federal processes through the Medicare Administrative Law Judge system.

What happens if my authorization expires? Coverage stops immediately. Submit renewal requests 2-4 weeks early to prevent gaps. If coverage lapses, contact Vertex GPS for potential bridge therapy while appealing.

Do I need specialty pharmacy for Trikafta? Yes. Trikafta is typically restricted to Humana's contracted specialty pharmacies. Verify network status before filling prescriptions.

What if I have drug interactions with Trikafta? Document the clinical rationale for continuing Trikafta despite interactions. Include monitoring plans and any dose adjustments in your medical necessity letter.

Counterforce Health: Streamlining Your Appeals

When facing complex prior authorization denials, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to craft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right clinical evidence and regulatory citations to support your case.

For Trikafta appeals specifically, Counterforce Health can help identify whether denials stem from PA criteria, step therapy requirements, or "not medically necessary" determinations, then draft responses that address Humana's exact policy language while incorporating FDA labeling, peer-reviewed studies, and CF care guidelines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Humana and consult with qualified healthcare professionals and insurance specialists for your specific situation. For additional help with Pennsylvania insurance issues, contact the Pennsylvania Insurance Department Consumer Services at 1-877-881-6388.

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