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

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

Answer Box: Getting Adynovate Covered by Humana in Michigan

Fastest Path: Humana requires prior authorization for Adynovate (bdanocog alfa pegol) with step therapy requirements. Submit documentation showing hemophilia A diagnosis (ICD-10: D66), factor VIII levels, bleeding history, and any prior factor VIII failures. Use J-code J7207 for billing. First step today: Confirm your Humana plan type (Medicare Advantage vs. Part D) and gather your factor VIII activity test results and bleeding episode records. Submit PA requests via Humana provider portal or fax 877-486-2621. Standard review takes 30 days; expedited available if medically urgent.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: Tracking Your Request
  9. Common Denial Prevention Tips
  10. Appeals Process for Michigan Members
  11. Costs and Financial Assistance
  12. FAQ

Who Should Use This Guide

This guide helps Michigan residents with Humana coverage navigate the prior authorization (PA) process for Adynovate, an extended half-life factor VIII product for hemophilia A. You'll find this useful if:

  • Your doctor prescribed Adynovate for hemophilia A treatment or prophylaxis
  • Humana denied initial coverage or requires step therapy
  • You're switching from another factor VIII product
  • You need to appeal a denial or quantity limitation

Expected outcome: With proper documentation, most medically appropriate Adynovate requests are approved within 30 days. Step therapy exceptions are commonly granted when standard factor VIII products have failed or caused adverse reactions.

Member & Plan Basics

Confirm Your Coverage Details

Before starting, verify these essentials:

Plan Type Identification

  • Medicare Advantage (Part C): Medical benefit coverage; 30-day standard review
  • Medicare Part D: Prescription drug coverage; 7-day standard review, 72-hour expedited
  • Commercial/Group: Varies by employer plan; check member portal

Key Coverage Requirements

  • Prior authorization: Required for all Humana plans
  • Formulary status: Typically Tier 5 (specialty)
  • Step therapy: May apply (try preferred factor VIII first)
  • Specialty pharmacy: Required through CenterWell Specialty Pharmacy
Tip: Call Humana member services at 1-800-281-6918 to confirm your specific plan's requirements before submitting documentation.

Clinical Criteria Requirements

Primary Indication Requirements

Requirement Documentation Needed Source
Hemophilia A diagnosis ICD-10: D66 Humana PA criteria
Factor VIII activity level <1% (severe), 1-5% (moderate) with bleeding history Clinical lab results
Bleeding episodes Documented frequency, location, severity Provider notes
Treatment goals Prophylaxis or on-demand therapy rationale Medical necessity letter

Step Therapy Considerations

Humana may require trial of preferred factor VIII products first, unless:

  • Patient currently stable on Adynovate (proof of paid claims within 12 months)
  • Previous factor VIII product caused adverse reactions or inadequate response
  • Medical contraindication to preferred products exists

Common preferred alternatives: Standard factor VIII products, other extended half-life options per formulary

Dosing Requirements

Prophylaxis limits (per UHC criteria - similar standards):

  • Adults/adolescents ≥12 years: ≤50 IU/kg per infusion, no more than twice weekly
  • Children <12 years: ≤70 IU/kg per infusion, no more than twice weekly

Coding and Billing Requirements

Essential Codes

HCPCS/J-Code: J7207 (1 unit = 1 IU of factor VIII activity) Primary diagnosis: D66 (Hereditary factor VIII deficiency) Place of service: Outpatient (11) or physician office (11) Revenue code: 0636 (for facility billing)

Billing Units Calculation

Bill the exact number of IUs administered. For example:

  • Patient weight: 70 kg
  • Prescribed dose: 40 IU/kg
  • Total dose: 2,800 IU
  • Bill: 2,800 units of J7207
Note: Medicare reimbursement uses Average Sales Price (ASP) + 6% methodology.

Documentation Packet Checklist

Required Clinical Documentation

Provider Letter of Medical Necessity must include:

  • Patient demographics and Humana member ID
  • Hemophilia A diagnosis with ICD-10: D66
  • Most recent factor VIII activity level and date of test
  • Bleeding episode history (frequency, location, severity)
  • Previous factor VIII treatments tried and outcomes
  • Rationale for Adynovate (extended half-life benefit)
  • Proposed dosing schedule and monitoring plan
  • Provider signature and credentials

Supporting Attachments

  • Recent factor VIII activity assay results
  • Bleeding episode log or clinic notes
  • Previous treatment records (if step therapy exception needed)
  • Current medication list
  • Any adverse reaction documentation
Clinician Corner: Counterforce Health helps providers create targeted, evidence-backed prior authorization requests by analyzing payer-specific requirements and drafting point-by-point rebuttals aligned to plan policies.

Submission Process

Step-by-Step Submission

1. Gather Complete Documentation (Provider/Staff)

  • Medical necessity letter with all required elements
  • Clinical notes and lab results
  • Previous treatment history if applicable

2. Submit via Preferred Method (Provider)

3. Include Required Form Fields

  • Patient name and Humana ID
  • Prescriber NPI and contact information
  • Requested medication: Adynovate (bdanocog alfa pegol)
  • J-code: J7207
  • Requested quantity and duration

4. Request Expedited Review if Applicable (Provider)

  • Include physician statement of medical urgency
  • Document potential harm from delay

Common Submission Errors to Avoid

  • Incomplete factor VIII activity documentation
  • Missing bleeding episode history
  • Incorrect J-code or billing units
  • Unsigned medical necessity letter
  • Wrong fax number or portal submission

Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy Process

Humana requires Adynovate dispensing through CenterWell Specialty Pharmacy:

Contact Information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Hours: Mon-Fri 8am-8pm, Sat 8am-6pm Central Time

Transfer Process

1. PA Approval Notification

  • CenterWell receives automatic notification of PA approval
  • Patient contacted within 24-48 hours

2. Prescription Transfer

  • Provide CenterWell with prescriber information
  • Confirm shipping address and delivery preferences
  • Review insurance coverage and copay

3. Shipment Coordination

  • Temperature-controlled shipping included
  • Tracking information provided
  • Clinical support available for administration questions

After Submission: Tracking Your Request

Timeline Expectations

Plan Type Standard Review Expedited Review Appeal Deadline
Medicare Advantage 30 calendar days 72 hours 65 days from denial
Medicare Part D 7 calendar days 72 hours 65 days from denial
Commercial Varies by plan 72 hours Check EOB

Status Monitoring

Week 1: Confirmation of receipt (save confirmation number) Week 2-3: Follow up if no response for standard review Week 4: Escalate if approaching deadline If denied: Begin appeal process immediately

Record all communication dates, reference numbers, and representative names.

Common Denial Prevention Tips

Five Critical Pitfalls and Solutions

1. Insufficient Bleeding History

  • Problem: Vague documentation of bleeding episodes
  • Solution: Provide specific dates, locations, severity scores, and treatment required

2. Missing Step Therapy Documentation

  • Problem: No evidence of trying preferred factor VIII products
  • Solution: Document previous treatments with specific outcomes, adverse events, or contraindications

3. Incorrect Dosing Justification

  • Problem: Requesting doses above plan limits without rationale
  • Solution: Provide weight-based calculations and clinical guidelines supporting dose

4. Incomplete Provider Letter

  • Problem: Generic template without patient-specific details
  • Solution: Include individual bleeding pattern, treatment response, and quality of life impact

5. Wrong Submission Method

  • Problem: Using outdated forms or incorrect fax numbers
  • Solution: Verify current submission requirements on Humana provider portal

Appeals Process for Michigan Members

Internal Appeal (First Level)

Deadline: 65 days from denial notice Method: Submit via Humana member portal or mail Timeline: 30 days for Medicare Advantage, 7 days for Part D Required: Denial letter, additional clinical documentation, provider support letter

External Review (Michigan DIFS)

If Humana's internal appeal is denied, Michigan residents have strong external review rights:

Michigan Department of Insurance and Financial Services (DIFS)

Michigan Advantage: DIFS external reviews are binding on insurers and often faster than the 60-day maximum, with impartial medical experts reviewing cases.

Expedited Appeals

For urgent medical needs:

  • Requirement: Physician letter stating delay would harm patient
  • Timeline: 72 hours for decision
  • Scope: Applies to both Humana internal and DIFS external reviews

Costs and Financial Assistance

Typical Cost Structure

Humana Medicare Advantage: 20% coinsurance after deductible Humana Part D: Tier 5 specialty copay (varies by plan) Commercial plans: Check specific formulary tier

Financial Assistance Options

Takeda Patient Assistance:

Hemophilia Organizations:

  • National Hemophilia Foundation assistance programs
  • State-specific support through Michigan hemophilia organizations

Medicare Extra Help: Low-income subsidy for Part D premiums and copays

FAQ

How long does Humana PA take in Michigan? Standard review is 30 days for Medicare Advantage, 7 days for Part D. Expedited review available in 72 hours with physician support letter.

What if Adynovate is non-formulary on my plan? Request formulary exception with medical necessity documentation. Step therapy may still apply, requiring trial of preferred alternatives first.

Can I request expedited appeal if denied? Yes, if your physician provides a letter stating that waiting would harm your health. Both Humana and Michigan DIFS offer 72-hour expedited reviews.

Does step therapy apply if I was stable on Adynovate outside Michigan? Generally no - if you have paid claims for Adynovate within the past 12 months, step therapy requirements typically don't apply.

What happens if I need Adynovate while traveling? Contact CenterWell Specialty Pharmacy to arrange shipping to your temporary location. Emergency supplies may be available through local specialty pharmacies with prior approval.

How do I prove medical necessity for prophylaxis vs. on-demand? Document bleeding frequency, joint damage risk, activity level, and quality of life impact. Severe hemophilia (<1% factor VIII) typically qualifies for prophylaxis.

Counterforce Health's platform helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, identifying the specific basis for rejection, and drafting targeted rebuttals with the right clinical evidence and regulatory requirements. Learn more at www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly for coverage determinations. For assistance with Michigan insurance appeals, contact DIFS at 877-999-6442.

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