How to Get Alecensa (Alectinib) Covered by Humana in Florida: Complete Guide to Prior Authorization and Appeals
Answer Box: Getting Alecensa Covered by Humana in Florida
Alecensa (alectinib) requires prior authorization from Humana Medicare Advantage and Part D plans in Florida. The fastest path to approval: (1) Submit complete ALK-positive test results with your PA request, (2) Document any prior therapy failures, and (3) Use Humana's provider portal for real-time processing. Start today by gathering your ALK fusion test report and treatment history. Appeals succeed in 72+ hours when clinical documentation is complete.
Submit PA via Humana Provider Portal
Table of Contents
- Coverage at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Playbook for Humana in Florida
- Clinician Corner: Medical Necessity Checklist
- When Step Therapy Blocks Coverage
- Scripts & Templates
- Costs & Patient Assistance
- When to Escalate to Florida Regulators
- FAQ
Coverage at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization Required | Must be approved before dispensing | All Humana MA/Part D plans in FL | Humana PA Lists |
| ALK-Positive Test Required | Molecular pathology report showing ALK fusion | CLIA-certified lab report | Humana Clinical Policy |
| Step Therapy May Apply | Try crizotinib first in some plans | Plan formulary document | Humana Step Therapy List |
| Appeals Deadline | 65 days from denial notice | Medicare regulations | Humana Appeals Process |
| Decision Timeline | 72 hours (standard), 24 hours (expedited) | CMS requirements | Medicare Appeals Guide |
Step-by-Step: Fastest Path to Approval
1. Confirm Your ALK-Positive Status
Who does it: Your oncologist's office
Document needed: Complete molecular pathology report showing ALK rearrangement
Timeline: Should already be in your file
Pro tip: The report must explicitly state "ALK-positive" or "ALK rearrangement detected"
2. Document Prior Treatments (If Any)
Who does it: Patient and care team
Documents needed: Records of previous cancer therapies, outcomes, and reasons for discontinuation
Where to submit: Include with PA request
Note: Even if Alecensa is first-line, document why it's the preferred choice
3. Submit Prior Authorization Request
Who does it: Your prescribing physician
How to submit: Humana Provider Portal (preferred) or phone 800-523-0023
Documents to include:
- ALK-positive test results
- Complete treatment history
- Medical necessity letter
- Patient demographics and insurance info
Timeline: Submit as soon as treatment decision is made
4. Track Your Request Status
Who does it: Patient or clinic staff
Where to check: Provider portal or call member services
Expected timeline: 72 hours for standard review, 24 hours if expedited
Follow up: Call if no response within expected timeframe
5. If Approved: Fill Prescription
Where: Specialty pharmacy (often required for Alecensa)
Cost: Check copay assistance programs before filling
Monitoring: Schedule required lab work per prescriber instructions
6. If Denied: File Appeal Immediately
Timeline: Within 65 days of denial notice
Documents: Original PA request plus additional supporting evidence
Process: See Appeals Playbook section below
7. Consider Peer-to-Peer Review
When: If initial PA is denied
Who participates: Your oncologist and Humana medical director
How to request: Call number provided in denial letter or contact provider services
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documents |
|---|---|---|
| "ALK status not documented" | Submit complete molecular pathology report | Original lab report with ALK rearrangement results |
| "Step therapy required" | Request exception with clinical justification | Letter explaining why crizotinib is inappropriate |
| "Not medically necessary" | Provide comprehensive treatment rationale | Detailed medical necessity letter with guidelines |
| "Incomplete clinical information" | Submit full treatment history | Prior therapy records, current staging, performance status |
| "Non-formulary drug" | Request formulary exception | Supporting statement from prescriber |
Appeals Playbook for Humana in Florida
Level 1: Internal Appeal (Redetermination)
- Deadline: 65 days from denial notice
- Decision timeline: 30 days (pre-service) or 60 days (post-service)
- How to file: Mail, fax, or online portal
- Address: Humana Grievance & Appeals Department, P.O. Box 14546, Lexington, KY 40512-4546
- Required: Member info, claim details, reason for appeal, supporting documents
Level 2: Independent Review
- When: If Level 1 is denied
- Timeline: Request within 65 days of Level 1 denial
- Process: Automatic referral to independent reviewer
- Cost: Free to member
Expedited Appeals
- When to use: Urgent medical need where delay could jeopardize health
- Timeline: 72 hours for decision
- How to request: Indicate "expedited" on appeal form and provide clinical justification
Required Appeal Documentation
- Member name, ID number, and contact information
- Specific service or medication being appealed
- Date of denial and reason given
- Prescriber's supporting statement
- Additional clinical evidence
- Desired resolution
Download Appeal Form (verify current form)
Clinician Corner: Medical Necessity Checklist
When drafting your medical necessity letter for Alecensa, include these essential elements:
Patient-Specific Factors
- Diagnosis: Non-small cell lung cancer with ALK rearrangement (include ICD-10 code)
- Stage and performance status: Current disease extent and functional status
- ALK testing methodology: FISH, IHC, or NGS results with laboratory certification
- Treatment goals: Tumor response, symptom control, quality of life
Clinical Rationale
- FDA indication: Alecensa is approved for metastatic ALK-positive NSCLC and adjuvant treatment
- Guideline support: Reference NCCN, ASCO, or other relevant treatment guidelines
- Comparative effectiveness: Why Alecensa vs. other ALK inhibitors for this patient
- Contraindications to alternatives: Document any reasons other options aren't suitable
Prior Treatment History
- Previous therapies: List all prior cancer treatments with dates and outcomes
- Reason for discontinuation: Progression, intolerance, or contraindication
- Response assessment: Imaging results, biomarker changes, symptom improvement
Monitoring Plan
- Laboratory monitoring: Liver function tests, CPK levels per FDA labeling
- Imaging schedule: Response assessment timeline
- Dose modifications: Plan for managing potential side effects
From our advocates: We've seen PA approvals happen within 24 hours when oncologists include specific language like "ALK-positive NSCLC confirmed by [methodology] on [date], with prior platinum-based chemotherapy failure documented by progression on [date]." The key is being specific about both the diagnosis and treatment history.
When Step Therapy Blocks Coverage
Some Humana plans require trying crizotinib before approving Alecensa. Here's how to navigate this:
Exception Criteria
- Clinical contraindication: Patient cannot take crizotinib due to drug interactions, organ dysfunction, or allergies
- Prior failure: Patient previously failed crizotinib (even if not on current plan)
- Urgent need: Delay in treatment could compromise outcomes
Documentation for Step Therapy Exception
- Letter from prescriber explaining clinical rationale
- Evidence of contraindication or prior failure
- Supporting literature if applicable
Alternative: Transition Policy
- New members: May get 31-day supply while exception is processed
- Existing therapy: Patients already on Alecensa before joining Humana typically continue coverage
Check Current Step Therapy Requirements
Scripts & Templates
Patient Phone Script for Humana
"Hi, I'm calling about prior authorization for Alecensa, generic name alectinib, for ALK-positive lung cancer. My member ID is [ID number]. My oncologist submitted the request on [date], and I'd like to check the status. Can you also tell me if any additional information is needed?"
Clinic Staff Script for Peer-to-Peer
"I'm calling to request a peer-to-peer review for [patient name], member ID [number], regarding the denial of Alecensa for ALK-positive NSCLC. Dr. [name] would like to discuss the clinical rationale with your medical director. When can we schedule this review?"
Email Template for Missing Records
"We're preparing a prior authorization request for Alecensa and need documentation of [specific information]. Could you please provide records showing [prior treatments/test results/dates] by [date]? This will help ensure a complete submission and faster approval."
Costs & Patient Assistance
Manufacturer Support
- Genentech Patient Foundation: Income-based assistance for eligible patients
- Co-pay assistance: May reduce out-of-pocket costs for commercially insured patients
- Free drug program: Available for uninsured patients meeting criteria
Apply for Genentech Assistance (verify eligibility requirements)
Additional Resources
- CancerCare Co-Payment Assistance Foundation: Helps with insurance copays
- Patient Access Network Foundation: Disease-specific funds for lung cancer patients
- Medicare Extra Help: Low-income subsidy for Medicare Part D costs
Cost Transparency
Alecensa's wholesale acquisition cost is approximately $19,466 per 240-capsule bottle (verify with current pricing). Most patients pay significantly less with insurance and assistance programs.
When to Escalate to Florida Regulators
If Humana repeatedly denies coverage despite strong clinical evidence, consider filing a complaint with Florida regulators:
Florida Department of Financial Services
- Purpose: Insurance complaints and external review requests
- Contact: 1-877-693-5236 or online complaint form
- Timeline: External review available after internal appeals are exhausted
- Cost: Free to consumers
When to File
- Humana fails to respond within required timelines
- Denial appears to violate coverage policy
- Internal appeals process seems flawed
- Pattern of inappropriate denials
Required Documentation
- All correspondence with Humana
- Medical records supporting need for Alecensa
- Evidence of policy violations
- Timeline of events
FAQ
Q: How long does Humana prior authorization take for Alecensa in Florida? A: Standard requests: 72 hours. Expedited requests (for urgent medical need): 24 hours. Submit through the provider portal for fastest processing.
Q: What if Alecensa isn't on Humana's formulary? A: Request a formulary exception with prescriber supporting statement. Decision required within 72 hours (24 hours if expedited).
Q: Can I get emergency supply while PA is pending? A: New Humana members may get a 31-day transition supply. Check with your pharmacy about emergency fill policies.
Q: Does step therapy apply if I failed crizotinib with another insurer? A: You can request a step therapy exception with documentation of prior failure. Include records from previous treatment.
Q: What counts as "expedited" for faster review? A: When delay could seriously jeopardize your life, health, or ability to regain maximum function. Your doctor must certify this need.
Q: Can family members file appeals on my behalf? A: Yes, with completed Appointment of Authorized Representative form or legal authorization.
Q: What if I disagree with Humana's medical director? A: Request external review through Florida's independent review process. This decision is binding on Humana.
Q: Are there alternatives if all appeals fail? A: Consider manufacturer assistance programs, clinical trials, or working with your oncologist to find covered alternatives with similar efficacy.
About Counterforce Health
Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Alecensa. Our platform analyzes denial letters, identifies the specific coverage gaps, and generates evidence-backed appeals that address payers' exact requirements. We help patients, clinicians, and specialty pharmacies navigate prior authorization challenges with targeted, professional-grade documentation that improves approval rates.
When navigating Humana's prior authorization process for Alecensa becomes overwhelming, Counterforce Health can provide the specialized support needed to build compelling medical necessity cases and appeals that speak directly to payer requirements.
Sources & Further Reading
- Humana Prior Authorization Lists
- Humana Appeals Process
- Florida Insurance Consumer Helpline
- Medicare Appeals Guide
- Alecensa FDA Label
- Genentech Patient Assistance
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with healthcare advocates or legal professionals specializing in insurance matters.
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