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

How to Get Acthar Gel Covered by Humana in Virginia: Complete Prior Authorization and Appeals Guide

Quick Answer: To get Acthar Gel covered by Humana in Virginia, you'll need prior authorization with proof of corticosteroid failure or contraindication. Submit through Humana's provider portal with detailed medical necessity documentation. If denied, you have 65 days to appeal internally, then can request Virginia's external review within 120 days. Start by having your doctor complete Humana's corticotropin products prior authorization form and gather records of previous steroid trials.

Table of Contents

  1. Understanding Humana's Acthar Gel Requirements
  2. Step-by-Step: Fastest Path to Approval
  3. Medical Necessity Documentation
  4. Common Denial Reasons & Solutions
  5. Appeals Process in Virginia
  6. Virginia External Review Rights
  7. Cost Assistance Programs
  8. FAQ
  9. Sources & Further Reading

Understanding Humana's Acthar Gel Requirements

Acthar Gel (repository corticotropin injection) requires prior authorization across all Humana plans in Virginia, including Medicare Advantage and commercial coverage. The medication costs tens of thousands of dollars per vial, making it one of the most strictly managed specialty drugs.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Provider portal or fax submission Humana PA Policy
Step Therapy Must try corticosteroids first Document failure/intolerance PA Criteria
Specialist Required Condition-specific specialist Neurologist, rheumatologist, etc. Policy requirements
Medical Necessity Letter Detailed clinical justification From prescribing physician Standard PA process
Approval Duration Plan year if criteria met Annual renewal required Humana Guidelines

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Indication

Who: Your specialist
Document needed: Clear diagnostic documentation with ICD-10 codes
Timeline: Before PA submission

Acthar Gel has several FDA-approved uses including infantile spasms, multiple sclerosis exacerbations, and certain rheumatologic conditions. Your diagnosis must align with covered indications.

2. Document Prior Corticosteroid Trials

Who: Your medical team
Documents needed: Treatment records showing specific medications, doses, duration, and outcomes
Key requirement: Must demonstrate failure, intolerance, or contraindication to corticosteroids

Note: For diagnostic testing of adrenocortical function, you need documented contraindication to cosyntropin instead.

3. Complete Humana's Prior Authorization Form

Who: Your prescriber
Form: Corticotropin Products PA form
Submission: Provider portal, fax, or phone
Timeline: Allow 72 hours for standard review, 24 hours for expedited

4. Submit Comprehensive Medical Records

Include:

  • Complete treatment history
  • Lab results and imaging
  • Specialist consultation notes
  • Previous authorization attempts (if any)
  • Detailed medical necessity letter

5. Follow Up on Decision

Timeline: 72 hours for standard decisions
If approved: Coverage typically granted for the plan year
If denied: You have 65 days to file an internal appeal

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your medical necessity letter should include:

✓ Patient's specific diagnosis with ICD-10 codes
✓ Complete corticosteroid trial history including:

  • Medication names and doses
  • Treatment duration
  • Specific side effects or lack of efficacy
  • Contraindications (if applicable)

✓ Clinical rationale for Acthar Gel:

  • Why corticosteroids aren't appropriate
  • Expected benefits of ACTH therapy
  • Treatment goals and monitoring plan

✓ Supporting evidence from:

  • FDA labeling
  • Relevant clinical guidelines
  • Published literature (when applicable)
Tip: For West syndrome (infantile spasms), approval rates are typically higher since this is a well-established FDA indication with limited alternatives.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"No prior steroid trial documented" Provide detailed treatment history Pharmacy records, clinic notes, hospital discharge summaries
"Corticosteroids not contraindicated" Document specific contraindications Medical records showing diabetes, osteoporosis, psychiatric effects, etc.
"Not medically necessary" Strengthen clinical justification Specialist letter, treatment guidelines, patient-specific factors
"Step therapy not completed" Request exception or document completion Prior authorization records, treatment failure documentation
"Experimental/investigational" Cite FDA approval and guidelines FDA labeling, clinical practice guidelines

Appeals Process in Virginia

If your initial prior authorization is denied, Virginia provides robust appeal rights through multiple levels.

Internal Appeals with Humana

Timeline: 65 days from denial notice
Who can appeal: Member, representative, or prescriber
Submission: Humana appeals portal or written request
Decision timeline:

  • Standard: 30 days for Medicare Advantage
  • Expedited: 72 hours if health is at risk

Peer-to-Peer Review

Before or during the appeals process, request a peer-to-peer conversation between your specialist and Humana's medical director. This allows direct clinical discussion of your case.

How to request: Contact Humana provider services
Preparation: Have all clinical documentation ready
Focus areas: Medical necessity, treatment failures, patient-specific factors

Virginia External Review Rights

If Humana's internal appeals don't result in approval, Virginia law provides independent external review through the State Corporation Commission (SCC) Bureau of Insurance.

External Review Process

Eligibility: Denials based on medical necessity, appropriateness, or experimental treatment
Timeline: Must file within 120 days of final internal denial
Forms: Form 216-A (External Review Request)
Submission:

Review Timeline

  • Standard review: 45 days
  • Expedited review: 72 hours (requires physician certification that delay could harm your health)
Important: Virginia's external review is conducted by independent medical experts and is binding on Humana. If approved, coverage must be provided within 1-3 days.

Getting Help in Virginia

The SCC's Bureau of Insurance provides free consumer assistance:

  • Phone: 1-877-310-6560
  • Services: Guidance on appeal rights, form completion, process navigation
  • Managed Care Ombudsman: Additional support for HMO and managed care issues

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and crafting targeted rebuttals with the right clinical evidence. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes more effectively.

Cost Assistance Programs

Manufacturer Support

Acthar Patient Support Program

Additional Resources

  • State pharmaceutical assistance programs (if available)
  • Foundation grants for rare disease medications
  • Hospital charity care programs for infusion treatments

FAQ

Q: How long does Humana's prior authorization process take in Virginia? A: Standard decisions are made within 72 hours of receiving complete documentation. Expedited reviews (when health is at serious risk) are decided within 24 hours.

Q: What if Acthar Gel isn't on Humana's formulary? A: You can request a formulary exception with your prescriber's statement that formulary alternatives are ineffective or harmful. The same medical necessity standards apply.

Q: Can I get expedited appeals in Virginia? A: Yes. For Humana internal appeals, expedited review is available if delay could seriously harm your health. Virginia's external review also offers expedited processing within 72 hours with physician certification.

Q: Does step therapy apply if I failed corticosteroids in another state? A: Yes, documented treatment failures from other states should count toward step therapy requirements. Ensure you have complete medical records from previous providers.

Q: What happens if Virginia's external review denies my appeal? A: The external review decision is final and binding. However, you retain rights to pursue legal action separately if you believe laws were violated.

Q: Are there special provisions for infantile spasms? A: Yes, Acthar Gel approval for West syndrome (infantile spasms) typically faces fewer barriers since it's a well-established FDA-approved indication with limited alternatives.

Q: How often do I need to renew prior authorization? A: Humana typically approves Acthar Gel for the plan year duration, requiring annual renewal with updated clinical documentation.

Q: Can I appeal if my doctor won't prescribe Acthar Gel? A: Insurance appeals address coverage denials, not prescribing decisions. If you believe Acthar Gel is appropriate, discuss with your specialist or seek a second opinion from another qualified physician.

From Our Advocates

We've seen cases where patients initially denied Acthar Gel coverage succeeded on appeal by providing more detailed documentation of corticosteroid side effects—not just "didn't work," but specific problems like uncontrolled blood sugar, bone loss, or psychiatric symptoms that made continued steroid use dangerous. The key is painting a complete clinical picture of why alternatives aren't viable for this specific patient.

When navigating complex specialty drug approvals, Counterforce Health helps streamline the process by automatically identifying the specific denial reasons and crafting evidence-based appeals that address payers' exact coverage criteria, potentially saving weeks in the approval timeline.

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual medical circumstances and specific plan benefits. Always consult with your healthcare provider and insurance plan for guidance specific to your situation.

Sources & Further Reading

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