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

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

Answer Box: Getting Acthar Gel Covered by Humana in Texas

Fastest path to approval: Humana requires prior authorization for Acthar Gel based on specific medical criteria, including documented failure or intolerance to corticosteroids. For infantile spasms (West syndrome), approval is typically straightforward with proper diagnosis. For MS exacerbations and other conditions, you must prove corticosteroid failure/contraindications.

First step today: Have your prescriber submit a prior authorization request through Humana's provider portal with complete medical records showing your diagnosis, prior treatments, and why corticosteroids aren't suitable. Texas law provides strong appeal rights if initially denied, including expedited external review for specialty drugs.

Table of Contents

  1. Why Texas State Rules Matter
  2. Humana's Coverage Criteria for Acthar Gel
  3. Prior Authorization Turnaround Standards
  4. Texas Step Therapy Protections
  5. Appeals Process: Internal to External Review
  6. Continuity of Care During Transitions
  7. When to File Complaints with Texas Regulators
  8. Practical Scripts and Documentation Tips
  9. Understanding Plan Type Limitations
  10. Quick Reference Resources
  11. FAQ

Why Texas State Rules Matter

Texas insurance laws create additional protections beyond federal Medicare requirements, especially for specialty drugs like Acthar Gel. These state protections interact with Humana's policies to give you stronger appeal rights and clearer timelines.

Key Texas advantages:

  • Immediate external review for specialty drug denials (bypasses standard internal appeals)
  • Step therapy override requirements with specific medical necessity criteria
  • Binding decisions from Independent Review Organizations (IROs)
  • Clear complaint process through the Texas Department of Insurance

For Humana Medicare Advantage members, you get both federal Medicare appeal rights and Texas state protections, creating multiple pathways to coverage.

Humana's Coverage Criteria for Acthar Gel

According to Humana's corticotropin policy, Acthar Gel requires prior authorization for all uses. Coverage criteria vary by condition:

Coverage at a Glance

Condition Requirements Documentation Needed Approval Duration
Infantile Spasms (West Syndrome) Confirmed diagnosis Medical records showing West syndrome Plan year
MS Exacerbations Acute exacerbation + corticosteroid failure/intolerance Prior steroid trials, side effects, contraindications Plan year
Rheumatoid Arthritis Active disease + corticosteroid issues Treatment history, steroid complications Plan year
Nephrotic Syndrome Active syndrome + steroid problems Lab results, prior therapy records Plan year

Medical Necessity Requirements

For all conditions except infantile spasms, you must document:

  1. Previous corticosteroid trial with intolerable side effects OR
  2. Medical contraindication to corticosteroids with provider attestation
  3. Clinical expectation that Acthar won't cause the same problems as steroids

Prior Authorization Turnaround Standards

Humana's decision timeline:

  • Standard requests: 7 calendar days for Part D drugs
  • Expedited requests: 72 hours when delay could harm your health
  • Appeals (redeterminations): 7 days standard, 72 hours expedited

Texas state requirements add:

  • Immediate IRO review available for specialty drug denials
  • No internal appeal required for drugs you're actively receiving
  • 5-day emergency decisions for life-threatening situations
Tip: Request expedited review if you're experiencing active MS exacerbations or uncontrolled infantile spasms. Cite medical urgency in your request.

Texas Step Therapy Protections

Texas Insurance Code requires insurers using step therapy to provide clear override processes. For Acthar Gel, this means Humana must approve coverage if you meet statutory exception criteria.

Step Therapy Override Criteria

Your prescriber can request an override using the state-mandated form if:

  • Required drug is contraindicated or likely to cause harm
  • Required drug is expected to be ineffective based on your clinical profile
  • You previously failed the required medication or similar drugs
  • Required drug is not in your best interest (would reduce daily functioning, worsen comorbid conditions, or significantly impact adherence)

Documentation That Helps

When requesting a step therapy exception, include:

  • Detailed side effect history from prior corticosteroid use
  • Specific contraindications (e.g., diabetes, osteoporosis, infection risk)
  • Clinical rationale explaining why Acthar's mechanism differs from steroids
  • Treatment goals and expected outcomes

Appeals Process: Internal to External Review

Step-by-Step Appeals for Humana Medicare Advantage

  1. File Internal Appeal (Redetermination)
  2. Request Independent Review Entity (IRE)
    • When: If internal appeal denied
    • Timeline: Automatic forwarding by Humana
    • Decision time: 7 days standard
  3. Administrative Law Judge Hearing
    • When: If IRE upholds denial and drug costs >$200
    • Timeline: 60 days to request
    • Process: Federal Medicare appeals process

Texas IRO Process (Alternative Path)

For specialty drugs like Acthar Gel, Texas provides an immediate IRO review option:

  • Bypass internal appeals completely
  • Request immediate review citing Texas Insurance Code §4201.3601
  • Binding decision that Humana must follow
  • Contact: Texas Department of Insurance IRO line at 1-866-554-4926

Continuity of Care During Transitions

If you're switching plans or Acthar Gel becomes non-formulary, both federal and Texas rules protect your access:

Transition Fill Rights

  • 30-day supply at retail pharmacies
  • 90-day supply in long-term care settings
  • Automatic coverage during transition period
  • Time to complete prior authorization or formulary exception

Grace Period Protections

Texas Medicare Advantage plans must provide continuity when:

  • Your prescriber leaves the network
  • Plan formulary changes mid-year
  • You switch between plans during open enrollment

Action step: Contact Humana immediately if you're notified of formulary changes affecting your Acthar Gel coverage.

When to File Complaints with Texas Regulators

File a complaint with the Texas Department of Insurance if:

  • Humana doesn't respond within required timeframes
  • Prior authorization process seems unreasonable
  • Appeal decisions don't follow Texas or federal law
  • You need help navigating the IRO process

Contact information:

  • Consumer hotline: 1-800-252-3439
  • IRO information: 1-866-554-4926
  • Online complaints: TDI website complaint portal

What to Include in Your Complaint

  • Policy number and member ID
  • Denial letters and appeal decisions
  • Medical records supporting necessity
  • Timeline of events and missed deadlines
  • Specific Texas law violations (if applicable)

Practical Scripts and Documentation Tips

Phone Script for Humana Customer Service

"I need to request prior authorization for Acthar Gel for [condition]. This is a specialty drug covered under your corticotropin policy. I have documentation of corticosteroid failure/intolerance. Can you connect me with utilization management and provide the fastest submission method?"

Medical Necessity Letter Checklist

Your prescriber should include:

  • Specific diagnosis with ICD-10 codes
  • Prior corticosteroid trials with dates, doses, and outcomes
  • Side effects experienced or contraindications present
  • Clinical rationale for Acthar's unique mechanism
  • Treatment goals and monitoring plan
  • Guideline support from FDA labeling or specialty society recommendations

Peer-to-Peer Review Request

If initially denied, request a peer-to-peer review:

"I'm requesting a peer-to-peer review for [patient name] regarding Acthar Gel denial. The reviewing physician should have expertise in [neurology/rheumatology/nephrology] and familiarity with ACTH therapy. When can this be scheduled?"

Understanding Plan Type Limitations

Important distinction: These Texas protections apply differently based on your plan type:

Fully Covered Plans

  • Humana Medicare Advantage: Full Texas and federal protections
  • Texas-regulated commercial plans: Complete state law protections
  • Medicaid managed care: State fair hearing process available

Limited Coverage Plans

  • ERISA self-funded employer plans: Federal appeals only
  • Federal employee plans: Federal process, not Texas IRO
  • Some grandfathered plans: May have different requirements
Note: Most individual Humana Medicare Advantage plans in Texas are fully subject to both state and federal protections.

Quick Reference Resources

Essential Forms and Contacts

  • Humana prior auth: Provider portal or member services
  • Texas step therapy exception: TDI-approved standardized form
  • IRO request: 1-866-554-4926
  • Medicare appeals: 1-800-MEDICARE (1-800-633-4227)

Consumer Assistance

  • Texas SHIP (Medicare help): 1-800-252-9240
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Disability Rights Texas: Advocacy for complex cases

Official Resources

FAQ

Q: How long does Humana prior authorization take for Acthar Gel in Texas? A: Standard requests receive decisions within 7 calendar days. Expedited requests (for urgent medical needs) are decided within 72 hours. Texas law provides additional protections if these timelines aren't met.

Q: What if Acthar Gel isn't on Humana's formulary? A: You can request a formulary exception with medical necessity documentation. Humana must provide a 30-day transition fill while reviewing your exception request.

Q: Can I get immediate external review in Texas? A: Yes, Texas law allows immediate IRO review for specialty drug denials, bypassing Humana's internal appeals. This is unique to Texas and provides faster resolution.

Q: Does step therapy apply if I failed corticosteroids outside Texas? A: Yes, prior treatment failures from other states count toward Texas step therapy exception criteria. Include complete medical records from previous providers.

Q: What's the difference between Medicare appeals and Texas IRO? A: Medicare appeals follow federal timelines and processes. Texas IRO provides an alternative, often faster path with binding decisions that Humana must follow.

Q: How much does Acthar Gel cost with Humana coverage? A: Costs depend on your specific plan's formulary tier and benefit phase. Contact Humana for exact copay/coinsurance amounts. Patient assistance programs may be available through the manufacturer.

Getting Help with Complex Cases

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-based responses. Their platform helps identify the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or medical necessity determinations—and drafts point-by-point rebuttals using the payer's own rules and relevant clinical evidence.

For complex Acthar Gel cases involving multiple denials or unclear medical necessity requirements, having expert support can make the difference between continued denials and successful coverage. The system pulls appropriate medical evidence from FDA labeling, peer-reviewed studies, and specialty guidelines while ensuring all procedural requirements are met for both Humana's policies and Texas appeal processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with appeals, contact the Texas Department of Insurance consumer hotline at 1-800-252-3439.

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