By Counterforce Health Team in Adynovate (bdanocog alfa pegol) —

How to Get Adynovate (bdanocog alfa pegol) Covered by Humana in Florida: Complete Prior Authorization Guide

Answer Box: Getting Adynovate Covered by Humana in Florida

Humana Medicare Advantage plans in Florida require prior authorization for Adynovate (bdanocog alfa pegol), a specialty hemophilia A treatment. To get approval: (1) Confirm your Humana plan type via MyHumana portal, (2) Have your hematologist submit a prior authorization request with hemophilia A diagnosis (ICD-10 D66), factor VIII levels <1-5%, and bleeding history documentation, (3) Submit via Humana's provider portal or fax to 800-594-5309. CenterWell Specialty Pharmacy is Humana's preferred vendor for dispensing. Appeals must be filed within 65 days if denied, with external review available through Florida's Department of Financial Services.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding and Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in Florida
  11. Quick Reference Checklist

Who Should Use This Guide

This guide helps Florida residents with Humana coverage who need Adynovate (bdanocog alfa pegol) approved for hemophilia A treatment. You'll benefit most if you:

  • Have severe or moderate hemophilia A requiring prophylaxis or extended half-life factor VIII
  • Face denials for "not medically necessary" or formulary placement issues
  • Need to document step therapy failures or quantity limit exceptions
  • Want to prevent common prior authorization pitfalls

Expected outcome: With proper documentation, most medically appropriate Adynovate requests get approved within 7-14 business days. Denials often stem from incomplete clinical documentation rather than coverage exclusions.

Member & Plan Basics

Confirm Your Coverage

First, verify your specific Humana plan type, as requirements differ:

  • Medicare Advantage (Part C): Requires PA for Adynovate in physician office, clinic, outpatient, or home settings
  • Medicare Part D: Specialty tier medication requiring formulary exception if non-preferred
  • Medicaid (Humana Healthy Horizons): In-network specialty pharmacy required

Check your plan details via MyHumana portal or call 1-800-281-6918.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Pre-approval needed before dispensing Humana PA Drug List
Specialty Tier Higher copay, specialty pharmacy required Plan formulary document
Step Therapy Must try preferred FVIII first PA criteria in provider portal
Quantity Limits Maximum monthly units based on weight/prophylaxis plan Clinical policy guidelines
ICD-10 Required D66 (Hemophilia A) must be documented Billing requirements

Clinical Criteria for Approval

Hemophilia A Severity Documentation

Humana requires clear evidence of hemophilia A severity based on factor VIII levels:

  • Severe: <1% factor VIII activity (highest priority for approval)
  • Moderate: 1-5% factor VIII activity
  • Mild: 5-40% factor VIII activity (requires additional justification)
Note: Document baseline factor VIII levels via one-stage clotting assay. Normal range is 50-150%.

Medical Necessity Criteria

Your hematologist must demonstrate:

  1. Confirmed diagnosis with appropriate ICD-10 coding (D66)
  2. Bleeding history supporting prophylaxis need (≥3 joint bleeds annually for severe cases)
  3. Prior therapy failures if step therapy applies
  4. Dosing rationale based on pharmacokinetics and target trough levels (>1-5% for prophylaxis)

Extended Half-Life Justification

For Adynovate specifically, document why extended half-life factor VIII is preferred over standard products:

  • Improved quality of life with less frequent dosing
  • Better adherence to prophylaxis regimen
  • Reduced venous access complications
  • Previous standard FVIII breakthrough bleeding

Coding and Billing Requirements

Essential Codes

  • ICD-10: D66 (Congenital factor VIII disorder)
  • HCPCS: J7209 (Injection, factor VIII recombinant, PEGylated, per 5 IU)
  • NDC: Verify current NDC for Adynovate vial size prescribed

Billing Documentation

Include in your prior authorization:

  • Total monthly international units (IU) needed
  • Infusion frequency (e.g., every 48-72 hours for prophylaxis)
  • Weight-based dosing calculations
  • Target trough factor VIII levels
Tip: Calculate quantity as total IU divided by 100, rounded to nearest whole number for billing purposes.

Documentation Packet Checklist

Provider Letter of Medical Necessity

Your hematologist should include:

  • Patient demographics and Humana member ID
  • Hemophilia A diagnosis with onset date
  • Current factor VIII level lab results
  • Detailed bleeding history (frequency, location, severity)
  • Prior factor VIII products tried, dates, and outcomes
  • Contraindications to formulary-preferred alternatives
  • Proposed Adynovate dosing regimen and rationale
  • Clinical goals and monitoring plan

Required Attachments

  • Recent factor VIII level lab report
  • Bleeding diary or treatment logs (if available)
  • Previous factor concentrate trial documentation
  • Hospital records for major bleeding episodes
  • Pharmacy records showing prior FVIII usage

Supporting Clinical Evidence

Reference these guidelines in your appeal:

Submission Process

How to Submit

Providers: Use one of these methods:

  • Humana provider portal (preferred)
  • Fax: 800-594-5309
  • Phone: 866-488-5995

Members: Call 866-773-5959 or submit via MyHumana portal

Required Forms

  • "Request for Medicare Prescription Drug Coverage Determination" (for Part D)
  • "Supporting Information for Exception Request or Prior Authorization"
  • Prescriber attestation form
Important: Use current form versions from Humana's provider portal. Outdated forms cause automatic rejections.

Timeline Expectations

  • Standard review: 72 hours for coverage determination
  • Expedited review: 24 hours (requires medical urgency documentation)
  • Part D appeals: 7 calendar days for decision

Specialty Pharmacy Routing

Preferred Network

CenterWell Specialty Pharmacy is Humana's primary specialty vendor for Adynovate:

  • Phone: 1-800-486-2668
  • Hours: Mon-Fri 8 a.m.–8 p.m. ET
  • Services: Prior auth coordination, financial assistance, unmarked delivery

Transfer Process

  1. Obtain PA approval first
  2. Have prescriber send prescription to CenterWell
  3. Verify insurance coverage and copay
  4. Schedule delivery (10-14 days via UPS/USPS)

Use Humana's pharmacy finder to locate additional in-network specialty pharmacies if needed.

After Submission: What to Expect

Confirmation and Tracking

  • Record your PA reference number
  • Check status via provider portal or member services
  • Follow up if no response within stated timeframes

Approval Notifications

Approvals typically include:

  • Authorized quantity and duration
  • Approved NDC and strength
  • Dispensing pharmacy requirements
  • Renewal date (usually 6-12 months)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit peer-reviewed studies on prophylaxis benefits; include bleeding frequency data
"Formulary alternative available" Document contraindications or failures with preferred products; request formulary exception
"Quantity exceeds medical necessity" Provide weight-based dosing calculations and target trough level rationale
"Incomplete documentation" Resubmit with all required clinical attachments and updated forms
"Step therapy not completed" Document previous standard FVIII trials or provide medical contraindication

Peer-to-Peer Review

If initially denied, request a peer-to-peer review where your hematologist speaks directly with Humana's medical director. This often resolves clinical disagreements quickly.

Appeals Process in Florida

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Timeline: 7 days for Part D decisions
  • How to file: MyHumana portal, phone, or mail
  • Required: Original denial letter, additional clinical documentation

External Review (Independent)

If internal appeal fails:

  • Deadline: 4 months after final internal denial
  • Process: Florida Department of Financial Services coordinates independent medical review
  • Contact: Florida Division of Consumer Services at 1-877-MY-FL-CFO
  • Cost: Free to consumer
Expedited appeals: Available for urgent medical situations with 72-hour decision timeline.

Quick Reference Checklist

Before You Start

  • Confirm Humana plan type and member ID
  • Verify Adynovate is prescribed by hematologist
  • Gather factor VIII level labs and bleeding history
  • Check if step therapy requirements apply

Documentation Must-Haves

  • ICD-10 D66 diagnosis documented
  • Factor VIII level <5% confirmed
  • Prior treatment history detailed
  • Medical necessity letter completed
  • Current prescription with NDC

Submission Checklist

  • Use current PA forms
  • Submit to correct department (pharmacy vs. medical)
  • Include all required attachments
  • Keep copies and confirmation numbers
  • Set calendar reminder for follow-up

From Our Advocates: "We've seen the biggest difference when families work closely with their hemophilia treatment center from the start. HTCs know exactly what documentation Humana needs and often have established relationships with the plan's medical directors. Don't try to navigate this alone—leverage their expertise."

When to Get Help

If you're struggling with Adynovate approval, Counterforce Health specializes in turning insurance denials into successful appeals. Our platform analyzes your specific denial reason, identifies gaps in documentation, and generates evidence-backed appeals tailored to Humana's requirements. We help patients, clinicians, and specialty pharmacies get prescription drugs approved by creating targeted rebuttals that align with each plan's own rules and clinical policies.

For immediate assistance with Florida insurance issues, contact the Florida Division of Consumer Services at 1-877-693-5236.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan for personalized guidance. Counterforce Health provides coverage advocacy services but cannot guarantee approval outcomes.

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