By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How Long Does It Take to Get Eylea/Lucentis Approved by Humana in Pennsylvania? Complete Timeline & Appeal Guide

Answer Box: Getting Eylea/Lucentis Approved by Humana in Pennsylvania

Timeline: Standard prior authorization takes 14 calendar days (shortening to 7 days in 2026); urgent requests processed within 72 hours. Humana requires step therapy documentation and OCT imaging for diabetic macular edema and wet AMD.

Fastest path to approval:

  1. Submit complete prior authorization via CoverMyMeds portal with OCT results and visual acuity measurements
  2. Document bevacizumab trial/failure or contraindication for step therapy exception
  3. If denied, file Pennsylvania external review within 4 months (53% success rate in 2024)

Start today: Contact your retinal specialist to gather OCT imaging, visual acuity records, and prior treatment history before submitting your Humana prior authorization request.

Table of Contents

What Affects Approval Timeline

Several factors influence how quickly Humana approves Eylea (aflibercept) or Lucentis (ranibizumab) in Pennsylvania:

Benefit Type Complexity

  • Medicare Advantage: Requires prior authorization through Evolent (formerly New Century Health) with 14-day standard timeline
  • Commercial plans: May have different requirements and faster processing
  • First 90 days rule: New Medicare Advantage members continuing active treatment may not need prior authorization initially

Documentation Completeness Complete submissions process faster. Humana's retinal specialists need:

  • Recent OCT scans showing retinal fluid or edema
  • Best-corrected visual acuity measurements
  • Diagnosis confirmation (ICD-10 codes for diabetic macular edema, wet AMD)
  • Step therapy documentation (bevacizumab trial/failure)

Clinical Urgency Mark requests as "expedited" if delay threatens vision. These receive 72-hour processing versus the standard 14-day timeline.

Note: Humana has a relatively low denial rate of 3.5% for prior authorization requests, suggesting good approval odds with proper documentation.

Pre-Submission Preparation (0-2 Days)

Documentation Checklist

Gather these materials before submitting your prior authorization:

Clinical Records

  • Recent OCT imaging (within 30 days)
  • Fluorescein angiography results (if available)
  • Visual acuity measurements (baseline and current)
  • Complete diagnosis with ICD-10 codes
  • Treatment history and response documentation

Insurance Information

  • Humana member ID and group number
  • Prescribing physician NPI number
  • Pharmacy information (for Part D coverage)
  • Previous authorization numbers (if reauthorizing)

Step Therapy Documentation

  • Bevacizumab trial records and outcomes
  • Documentation of intolerance or contraindications
  • Clinical rationale for preferred agent

Verification Steps

  1. Confirm formulary status on Humana's drug list
  2. Check prior authorization requirements via Humana's PA search tool
  3. Verify provider network status to avoid coverage issues

Submission to Initial Review (1-5 Days)

Online Submission Process

Primary Portal: Use CoverMyMeds for fastest processing

  • Upload all supporting documents in PDF format
  • Select "expedited" if clinically urgent
  • Include complete prescriber attestation

Alternative Methods:

  • Fax: Use Humana's provider-specific fax numbers
  • Phone: Call Humana Pharmacy Clinical Review at 800-555-CLIN (2546)

What Reviewers Check First

Humana's clinical reviewers prioritize:

  1. Medical necessity criteria alignment with FDA labeling
  2. Step therapy compliance or documented exceptions
  3. Dosing appropriateness for indication and patient weight
  4. Site of care requirements for intravitreal injections
Tip: Submit during business hours Monday-Thursday for fastest initial review assignment.

Additional Information Requests (1-7 Days)

If Humana requests additional information, respond within 10 business days to avoid denial. Common requests include:

Missing Clinical Data

  • More recent OCT imaging
  • Detailed visual acuity progression
  • Additional specialist consultation notes

Step Therapy Clarification

  • Specific bevacizumab dosing and duration tried
  • Documented adverse reactions or lack of efficacy
  • Contraindication details with clinical rationale

Quick Response Strategies:

  • Use the same portal for supplemental submissions
  • Reference the original PA request number
  • Include a cover letter summarizing new information

Decision Window & Outcomes

Typical Timeline

  • Standard requests: 14 calendar days from complete submission
  • Expedited requests: 72 hours maximum
  • Incomplete submissions: Additional 5-10 days after information provided

Reading Approval Letters

Full Approval: Covers requested quantity and duration Partial Approval: May limit injection frequency or total doses Conditional Approval: Requires specific monitoring or follow-up

Coverage Details

Approved requests typically include:

  • Specific NDC/J-codes covered
  • Maximum quantity per fill
  • Authorized injection sites (ophthalmologist office, ASC)
  • Reauthorization requirements

If Denied: Pennsylvania Appeal Process

Pennsylvania residents have strong appeal rights with high success rates.

Internal Appeal (Required First Step)

Timeline: File within 60 days of denial notice Process: Submit via Humana member portal or mail Response time: 30 days for standard, 72 hours for expedited

Pennsylvania External Review

If internal appeal fails, Pennsylvania's Independent External Review Program offers:

  • 53% success rate in overturning denials (2024 data)
  • Free process for consumers
  • Binding decisions on insurers

How to File:

  1. Complete internal Humana appeal first
  2. Submit external review request at pa.gov/reviewmyclaim
  3. Include denial letters and supporting medical records
  4. Await independent medical reviewer decision (60 days standard, 72 hours expedited)
From our advocates: We've seen external reviews succeed when patients include detailed letters from their retinal specialists explaining why bevacizumab failed and why Eylea or Lucentis is specifically needed. The independent reviewers appreciate comprehensive clinical rationale that directly addresses the original denial reasons.

Appeal Support Resources

  • Pennsylvania Insurance Department: 1-877-881-6388
  • Free legal assistance: Pennsylvania Health Law Project
  • Counterforce Health: Automated appeal letter generation with evidence-backed rebuttals

Renewal Cycles & Maintenance

Reauthorization Requirements

Most approvals require renewal every 6-12 months with:

  • Updated OCT imaging showing continued need
  • Visual acuity monitoring results
  • Treatment response documentation
  • Ongoing step therapy compliance

What Speeds Renewals

  • Consistent provider: Same retinal specialist reduces review time
  • Complete response documentation: Show measurable improvement or stability
  • Early submission: File 30 days before authorization expires

Timeline Visual & Milestones

Milestone Timeline Action Required
Pre-submission 0-2 days Gather OCT, visual acuity, step therapy records
Initial submission Day 1 Submit via CoverMyMeds with complete documentation
Under review Days 2-5 Monitor portal for information requests
Additional info Days 6-12 Respond to any clinical questions within 10 days
Decision Day 14 Receive approval/denial notification
Internal appeal Days 15-44 File if denied (30-day response time)
External review Days 45-105 Pennsylvania independent review (60 days)

Time-Saving Tips

Portal Optimization

  • Create provider accounts in CoverMyMeds for status tracking
  • Save templates with standard clinical language
  • Upload high-quality PDFs to avoid resubmission requests

Bundled Evidence Strategy

Submit comprehensive packages including:

  • Clinical notes with clear medical necessity statement
  • Imaging reports with radiologist interpretation
  • Prior therapy documentation with specific outcomes
  • Prescriber attestation letter

Direct Specialty Routing

  • Use ophthalmology-specific PA forms when available
  • Reference Humana's retinal drug policies by number
  • Include relevant CPT codes (67028 for intravitreal injection)

For complex cases requiring comprehensive appeal strategies, Counterforce Health helps patients and providers generate targeted, evidence-backed appeals that align with Humana's specific coverage criteria and Pennsylvania's regulatory requirements.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not met Document bevacizumab trial failure Specific dosing, duration, lack of response
Missing OCT imaging Submit recent scans with interpretation OCT within 30 days showing retinal pathology
Insufficient visual acuity decline Provide serial measurements ETDRS or Snellen charts over time
Non-formulary status Request formulary exception Medical necessity letter with clinical rationale
Quantity limits exceeded Justify dosing frequency Treatment guidelines and response monitoring

FAQ

How long does Humana prior authorization take in Pennsylvania? Standard requests: 14 calendar days. Expedited requests for urgent cases: 72 hours maximum.

What if Eylea/Lucentis is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Include step therapy trials and clinical rationale for the specific agent.

Can I request an expedited appeal in Pennsylvania? Yes, both Humana internal appeals and Pennsylvania external reviews offer expedited processing for urgent clinical situations threatening vision.

Does step therapy apply if I tried bevacizumab outside Pennsylvania? Yes, document out-of-state treatment history with complete records. Humana accepts properly documented prior therapy regardless of location.

What happens if my external review is approved? Humana must immediately provide coverage, including retroactive payment if you paid out-of-pocket during the appeal process.

How much do these medications cost without insurance? Eylea and Lucentis typically cost $1,200-$2,500 per injection. Manufacturer patient assistance programs may help reduce costs during appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Prior authorization requirements and appeal processes may change. Always verify current policies with Humana and consult healthcare providers for medical decisions. For personalized assistance with complex appeals, Counterforce Health provides automated tools to help patients and clinicians navigate insurance denials with targeted, evidence-based appeal strategies.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.