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

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

Answer Box: Getting Acthar Gel Covered by Humana in Washington

Humana Medicare Advantage requires prior authorization for Acthar Gel (repository corticotropin injection) under their Corticotropin Products policy. Coverage applies to FDA-labeled indications like infantile spasms and MS exacerbations, with documented corticosteroid failure required for most conditions except infantile spasms. First step: Your prescriber submits a PA request via Humana's provider portal or fax (1-888-790-9999) with complete medical records. If denied, appeal within 65 days. Washington residents have additional protection through external review by certified Independent Review Organizations (IROs) after exhausting internal appeals.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Mandatory for all Acthar Gel uses Humana provider portal or fax 1-888-790-9999 Humana PA Policy
Covered Indications Infantile spasms, MS exacerbations, diagnostic testing, select rheumatologic conditions FDA label + medical necessity documentation Humana Corticotropin Policy
Step Therapy Corticosteroid trial/failure required (except infantile spasms) Prior therapy documentation in medical records Humana PA Requirements
Appeals Deadline 65 days from denial notice (Medicare Part D) Denial letter or EOB Medicare Appeals Guide
External Review Available after internal appeals; 180 days to request Washington Office of Insurance Commissioner WA RCW 48.43.535

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Day 1)

  • Insurance card and member ID
  • Complete diagnosis with ICD-10 codes (G40.824 for infantile spasms, G35 for MS)
  • Prior corticosteroid therapy records (doses, duration, outcomes)
  • Recent clinical notes and test results (EEG for spasms, MRI for MS)

2. Prescriber Submits PA Request (Day 1-2) Submit via Humana provider portal or fax 1-888-790-9999 with:

  • Completed PA form
  • Medical necessity letter
  • Supporting clinical documentation
  • NDC/HCPCS codes for billing

3. Track PA Status (Days 3-7)

  • Standard review: 7 days
  • Expedited review: 72 hours (if health jeopardized)
  • Check status via provider portal or call Humana

4. If Approved: Coordinate Specialty Pharmacy (Day 8+) Acthar Gel requires specialty pharmacy due to high cost and handling requirements.

5. If Denied: File Internal Appeal (Within 65 Days) Submit written appeal with additional evidence and medical necessity justification.

6. External Review if Needed (Within 180 Days) Contact Washington Office of Insurance Commissioner at 1-800-562-6900 for IRO review.

Read the Denial: Decode Reason Codes

Understanding your denial letter is crucial for crafting an effective appeal. Common Humana denial reasons for Acthar Gel include:

  • "Not medically necessary": Requires stronger clinical justification and evidence of corticosteroid failure
  • "Step therapy not met": Need documentation of prior corticosteroid trials and outcomes
  • "Non-formulary drug": Request formulary exception with medical necessity letter
  • "Quantity limits exceeded": Justify dosing based on FDA labeling and clinical guidelines
  • "Missing documentation": Resubmit with complete medical records and prescriber attestation
Note: Humana's Medicare Advantage PA denial rate is approximately 3.5% (2023), among the lowest of major plans, but denials that occur often stem from incomplete documentation.

Clinician Corner: Medical Necessity Letter

A strong medical necessity letter should include these key elements:

Clinical History & Diagnosis

  • Patient demographics and specific diagnosis with ICD-10 codes
  • Symptom severity and functional impact
  • Relevant test results (EEG, MRI, lab values)

Prior Treatment Failures

  • Specific corticosteroids tried (prednisone, methylprednisolone)
  • Doses and duration of treatment
  • Documented outcomes: lack of efficacy, adverse effects, contraindications
  • Alternative therapies attempted and results

Medical Necessity Justification

  • Why Acthar Gel is superior to alternatives for this patient
  • Expected clinical outcomes and monitoring plan
  • Citations from FDA labeling and clinical guidelines
  • Contraindications to other therapies

Supporting Evidence

  • Recent peer-reviewed studies
  • Professional society guidelines
  • FDA package insert references
  • Specialist consultation notes

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals aligned with each plan's requirements.

Appeals Playbook for Humana in Washington

Internal Appeals Process

Level 1: Redetermination

  • Timeline: File within 65 days of denial notice
  • Decision: 7 days (standard) or 72 hours (expedited)
  • How to file: Written request via mail, fax, or online portal
  • Required documents: Denial letter, additional medical evidence, prescriber support

Level 2: Reconsideration (if Level 1 denied)

  • Timeline: File within 60 days of redetermination denial
  • Decision: 30 days
  • Review: Independent medical review by Qualified Independent Contractor (QIC)

Peer-to-Peer Review

Request a peer-to-peer call with Humana's medical director before formal appeal:

  • Call Humana provider services to schedule
  • Prepare 5-7 minute summary of medical necessity
  • Focus on unique clinical circumstances and prior therapy failures
  • Follow up with written documentation

Expedited Appeals

Available when standard timeframes could jeopardize health:

  • Check "expedited" on appeal forms
  • Prescriber must attest to urgency
  • Decision within 72 hours
  • Common for acute MS exacerbations or uncontrolled infantile spasms

Washington State External Review Process

If Humana denies your internal appeals, Washington residents have additional protection through external review.

Eligibility

  • Must exhaust internal appeals first
  • Applies to medical necessity determinations
  • Available for experimental/investigational treatment disputes

How to Request

  1. Submit written request within 180 days of final internal denial
  2. Contact Washington Office of Insurance Commissioner: 1-800-562-6900
  3. Include denial letters, medical records, and supporting documentation
  4. OIC assigns certified Independent Review Organization (IRO)

Timeline

  • Standard review: Decision within 45 days
  • Expedited review: 72 hours (if health jeopardized)
  • Enrollee input: 5 business days to submit additional information

Outcome IRO decisions are binding on Humana. If overturned, Humana must provide coverage.

From our advocates: We've seen patients successfully overturn Acthar Gel denials by demonstrating clear corticosteroid failure with specific doses, durations, and documented adverse effects. The key is comprehensive documentation showing why alternatives won't work for this specific patient's clinical situation.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not met Document corticosteroid trials with specific outcomes Pharmacy records, clinical notes showing failure/intolerance
Not medically necessary Strengthen clinical justification with guidelines FDA labeling, specialty society recommendations, peer-reviewed studies
Quantity limits exceeded Justify dosing per FDA labeling Package insert, dosing calculator, clinical rationale
Non-formulary status Request formulary exception Medical necessity letter, alternative drug contraindications
Missing documentation Resubmit complete package All required forms, clinical notes, test results

Scripts & Templates

Patient Phone Script for Humana

"Hello, I'm calling about my Acthar Gel prior authorization that was denied. My member ID is [ID]. I'd like to understand the specific reason for denial and what additional information is needed for approval. Can you also tell me about the appeals process and deadlines?"

Clinic Staff Script for PA Submission

"I'm submitting a prior authorization for Acthar Gel for [patient name], member ID [ID]. The patient has infantile spasms/MS exacerbations with documented corticosteroid failure. I'm faxing the complete medical necessity letter and supporting documentation to 1-888-790-9999. Can you confirm receipt and provide a reference number?"

Email Template for Medical Records

"Subject: Urgent - Medical Records Needed for Acthar Gel Appeal

We need the following records for [patient name] to support their Acthar Gel appeal:

  • All corticosteroid prescriptions from [date range]
  • Clinical notes documenting treatment failures
  • Most recent EEG/MRI results
  • Specialist consultation reports

Please send by [date] to ensure we meet the appeal deadline. Thank you."

Costs & Savings Options

Manufacturer Support

  • Acthar Patient Support Program: Copay assistance and free drug programs for eligible patients
  • Coverage determination support and appeal assistance
  • Patient advocacy services

Alternative Funding

  • Patient advocacy foundations for rare disease medications
  • State pharmaceutical assistance programs
  • Hospital charity care programs for uninsured costs

Specialty Pharmacy Coordination Acthar Gel requires specialty pharmacy due to cost (typically $10,000s per vial) and handling requirements. Work with your plan's preferred specialty pharmacy network.

FAQ

How long does Humana PA take in Washington? Standard prior authorization decisions take up to 7 days. Expedited reviews (when health is jeopardized) are decided within 72 hours.

What if Acthar Gel is non-formulary on my Humana plan? Request a formulary exception with a medical necessity letter showing why formulary alternatives are ineffective or cause adverse effects for your specific condition.

Can I request an expedited appeal? Yes, if standard timeframes could jeopardize your health. Your prescriber must attest to the urgency, and decisions come within 72 hours.

Does step therapy apply if I failed corticosteroids outside Washington? Yes, documented corticosteroid failures from any state count toward step therapy requirements. Ensure you have complete pharmacy and medical records.

What's the difference between internal and external review? Internal appeals are reviewed by Humana. External review is conducted by independent medical experts assigned by Washington's Office of Insurance Commissioner and is binding on Humana.

Who can help me with my appeal in Washington? Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 for free consumer advocacy assistance with insurance disputes.

When facing complex prior authorization requirements and potential appeals, Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted appeals that address specific plan policies and requirements, increasing the likelihood of approval for critical medications like Acthar Gel.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Appeal processes and requirements may change; verify current procedures with your plan and state regulators.

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