By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

How to Get Acthar Gel Covered by Humana in New York: Prior Authorization, Appeals, and State Protections Guide

Answer Box: Getting Acthar Gel Covered by Humana in New York

Humana requires prior authorization for Acthar Gel under their Corticotropin Products policy (effective 2024). For approval, you need: (1) documented covered indication like infantile spasms or MS exacerbations, (2) proof of corticosteroid failure/intolerance except for infantile spasms, and (3) specialist attestation. First step today: Have your prescriber submit a PA request via Humana's provider portal with complete medical records. If denied, you have 65 days to appeal internally, then 4 months for New York's external review through the Department of Financial Services.

Table of Contents

  1. Understanding Humana's Acthar Gel Policy
  2. Coverage Requirements at a Glance
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Playbook for Humana in New York
  6. Medical Necessity Documentation
  7. New York External Appeal Process
  8. Cost Assistance and Patient Support
  9. When to Escalate Beyond Appeals
  10. FAQ

Understanding Humana's Acthar Gel Policy

Humana Medicare Advantage plans require prior authorization for Acthar Gel (repository corticotropin injection) under their Corticotropin Products policy effective January 1, 2024. This policy groups Acthar Gel with Purified Cortrophin Gel as specialty drugs requiring strict medical necessity review.

The policy applies to all covered uses of Acthar Gel, whether billed under your pharmacy benefit (Part D) or medical benefit (Part B for professionally administered injections). Humana's approach reflects the drug's extremely high cost—typically tens of thousands of dollars per vial—and the availability of lower-cost corticosteroid alternatives for most conditions.

Note: Humana's Medicare Advantage prior authorization denial rate is approximately 3.5% (2023), among the lowest of major plans, but denials that occur often center on formulary placement or incomplete documentation.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all uses Humana provider portal Humana PA Policy
Covered Indications Infantile spasms, MS exacerbations, select rheumatologic/renal conditions FDA label, policy document FDA Prescribing Information
Step Therapy Corticosteroid trial required (except infantile spasms) Medical records Humana policy
Specialist Involvement Neurologist for MS, pediatric neurologist for spasms Provider notes Clinical documentation
Appeals Deadline 65 days from denial notice Denial letter Medicare Appeals Process

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Prior Treatments

Who: You and your prescriber
What: Gather documentation of your condition and any previous corticosteroid trials
Timeline: Before PA submission

For infantile spasms, collect EEG results showing hypsarrhythmia and pediatric neurology notes. For MS exacerbations, document acute relapse symptoms and prior high-dose steroid treatments (like IV methylprednisolone).

2. Have Your Prescriber Submit the PA Request

Who: Your prescriber's office
What: Complete Humana's prior authorization form via their provider portal or fax
Timeline: Allow 7 days for standard review, 72 hours for expedited

The request must include your exact diagnosis with ICD-10 codes, detailed treatment history, and clinical rationale for Acthar Gel specifically.

3. Request Expedited Review if Appropriate

Who: Your prescriber
What: Mark the PA request as expedited if delay could seriously harm your health
Timeline: 72-hour decision for expedited requests

This applies to acute MS relapses, uncontrolled infantile spasms, or situations where waiting could cause irreversible damage.

4. Monitor the Decision

Who: You and your prescriber's office
What: Track the PA status through Humana's portal or by calling member services
Timeline: Standard decisions within 7 days, expedited within 72 hours

5. If Approved, Coordinate Specialty Pharmacy

Who: Your prescriber and pharmacy
What: Acthar Gel requires specialty pharmacy dispensing due to its cost and handling requirements
Timeline: 2-3 business days for specialty pharmacy coordination

6. If Denied, Prepare Your Appeal Immediately

Who: You with prescriber support
What: Request the complete denial letter and begin gathering appeal documentation
Timeline: Start within 5-7 days of denial to meet deadlines

7. Submit Internal Appeal with Enhanced Documentation

Who: You or your prescriber
What: File formal appeal with additional medical evidence and peer-reviewed literature
Timeline: Submit within 65 days of denial notice

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient corticosteroid trial Document specific drugs, doses, duration, and outcomes Pharmacy records, clinic notes showing "prednisone 60mg daily × 14 days caused severe hypertension"
Not medically necessary Provide specialist attestation and guideline references Neurology consultation, AAN MS guidelines, FDA label excerpts
Alternative therapies available Detail contraindications or failures of alternatives Allergy documentation, prior adverse events, specialist letter
Quantity limits exceeded Submit dosing calculations based on body surface area Height/weight, BSA calculation, monitoring plan
Experimental/investigational use Cite FDA-approved indications and peer-reviewed evidence FDA label, published studies, specialist society guidelines

Counterforce Health helps patients and clinicians navigate these complex prior authorization requirements by analyzing denial letters and creating targeted, evidence-backed appeals that address each specific concern raised by the insurance plan.

Appeals Playbook for Humana in New York

Internal Appeals (First Level)

Timeline: Must file within 65 days of denial notice
Decision Time: 7 days standard, 72 hours expedited
How to File: Through Humana member portal or by mail

Include your complete denial letter, additional medical records, and a detailed letter from your prescriber explaining why Acthar Gel is medically necessary for your specific condition.

Medicare Redetermination (Second Level)

Timeline: Must file within 65 days of first-level denial
Decision Time: 7 days standard, 72 hours expedited
How to File: Use Medicare's standard redetermination process

This level involves an independent review by Humana's clinical team who weren't involved in the initial decision.

Clinician Corner: For appeals, structure your medical necessity letter around three key elements: (1) the patient's specific diagnosis and severity, (2) documented failure or contraindication to standard corticosteroids with specific examples, and (3) clinical rationale for why Acthar Gel's unique mechanism (ACTH stimulation vs. direct steroid effect) is necessary for this patient.

Medical Necessity Documentation

For Infantile Spasms (West Syndrome)

  • Confirmed diagnosis by pediatric neurologist
  • EEG showing hypsarrhythmia or other epileptiform patterns
  • Video documentation of spasms if available
  • Age confirmation (typically under 2 years)
  • Treatment plan with specific dosing (typically up to 150 units/m²/day)

For Multiple Sclerosis Exacerbations

  • Neurologist confirmation of acute relapse
  • MRI evidence of new or enhancing lesions (if available)
  • Documentation of high-dose corticosteroid trial: "Patient received IV methylprednisolone 1g daily × 5 days in March 2024 with minimal improvement in EDSS score"
  • Contraindications to repeat steroid use: uncontrolled diabetes, active infection, severe psychiatric effects

For Other Conditions

  • Rheumatologic conditions: Rheumatologist attestation, failed DMARD trials
  • Nephrotic syndrome: Nephrology consultation, proteinuria labs, steroid intolerance documentation

New York External Appeal Process

If Humana denies your internal appeals, New York residents have strong additional protections through the Department of Financial Services external appeal program.

Eligibility and Timeline

  • Deadline: 4 months from Humana's final adverse determination
  • Cost: Up to $25 (waived for Medicaid or financial hardship)
  • Decision Time: 72 hours for formulary exceptions, 30 days for standard appeals

How to File

  1. Download the New York State External Appeal Application
  2. Complete patient and prescriber sections fully
  3. Attach Humana's final denial letter and supporting medical records
  4. Submit online, by fax to (800) 332-2729, or by mail

Expedited External Appeals

Request expedited review if your prescriber attests that waiting 30 days would seriously jeopardize your life, health, or ability to regain function. For formulary exceptions like Acthar Gel, expedited appeals receive decisions within 24 hours.

The external appeal decision is binding on Humana—if the independent medical reviewer overturns the denial, Humana must cover Acthar Gel as determined.

Cost Assistance and Patient Support

Manufacturer Programs

Mallinckrodt offers the Acthar Patient Assistance Program for eligible patients with FDA-approved indications. The program may provide financial assistance for copays or, in some cases, free medication for qualifying uninsured patients.

Specialty Pharmacy Requirements

Acthar Gel requires specialty pharmacy dispensing due to its high cost and specific handling requirements. Your prescriber will need to coordinate with Humana's preferred specialty pharmacy network for fulfillment.

Foundation Assistance

Several rare disease foundations provide grants for specialty medications. Organizations like the HealthWell Foundation and Patient Access Network Foundation may have funds available for neurologic or autoimmune conditions requiring Acthar Gel.

When to Escalate Beyond Appeals

File a Complaint with New York Regulators

If you believe Humana is inappropriately denying coverage or not following proper procedures, file a complaint with the New York Department of Financial Services. Include:

  • Copy of your denial letters and appeals
  • Timeline of events
  • Documentation showing the denial may violate New York insurance law

Contact Community Health Advocates

Community Health Advocates offers free assistance to New York residents dealing with insurance denials. Call their helpline at 888-614-5400 for personalized guidance on your Acthar Gel appeal.

Medicare Beneficiary Ombudsman

For Medicare Advantage issues, you can also contact the Medicare Beneficiary Ombudsman if you believe Humana is not following Medicare rules for prior authorization or appeals.

FAQ

How long does Humana's prior authorization take for Acthar Gel? Standard PA decisions are made within 7 calendar days. Expedited requests (when delay could harm your health) receive decisions within 72 hours.

What if Acthar Gel is non-formulary on my Humana plan? You can request a formulary exception through Humana's coverage determination process. Your prescriber must demonstrate that formulary alternatives would be less effective or cause adverse effects.

Can I request an expedited appeal if my condition is urgent? Yes. For acute MS relapses or uncontrolled infantile spasms, request expedited review at both the PA and appeal levels. Include prescriber attestation about the urgency.

Does New York's external appeal process apply to Medicare Advantage? Yes, New York's external appeal law covers Humana Medicare Advantage plans. You have 4 months from Humana's final denial to file with the Department of Financial Services.

What happens if I'm already taking Acthar Gel and Humana denies continuation? Request an expedited appeal immediately, noting that you're on a current course of treatment. New York allows 24-hour decisions for urgent formulary exceptions involving ongoing therapy.

How much does Acthar Gel cost without insurance? A single 5-mL vial typically costs tens of thousands of dollars. This is why securing insurance coverage through proper prior authorization and appeals is crucial.

Can my doctor do a peer-to-peer review with Humana? Yes, your prescriber can request a peer-to-peer call with Humana's medical director to discuss your case. This is often effective for complex cases where written documentation alone may not convey the full clinical picture.

What if I've failed corticosteroids outside of New York? Documentation of corticosteroid failure from other states is valid for Humana's review. Ensure your prescriber includes complete records with specific drugs, doses, duration, and outcomes.

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 work with your prescriber's office for prior authorization submissions.

Need help with your Acthar Gel appeal? Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses that address each plan's specific requirements.

Sources & Further Reading

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