By Counterforce Health Team in Alprolix (coagulation factor IX, rFIXFc; eftrenonacog alfa) —

How to Get Alprolix (Factor IX) Covered by Humana in New York: Complete Guide with Forms and Appeal Process

Answer Box: Getting Alprolix Covered by Humana in New York

Alprolix (coagulation factor IX) requires prior authorization from Humana Medicare Advantage plans. Your fastest path to approval: (1) Have your hematologist submit a PA request to Humana at 866-461-7273 or fax 888-447-3430 with clinical documentation showing hemophilia B diagnosis and medical necessity, (2) If denied, file an internal appeal within 65 days, then (3) Request a New York State external review through DFS within 4 months. Start today by calling Humana to confirm your specific plan requirements and gather your medical records.

Table of Contents

Verify Your Plan and Find the Right Forms

Before starting any authorization process, confirm your exact Humana plan type and coverage details. Alprolix (coagulation factor IX, rFIXFc; eftrenonacog alfa) is a specialty hemophilia medication that requires prior authorization across Humana's Medicare Advantage plans.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all Humana Medicare Advantage plans Humana PA List 2024 Humana PA Policy
Specialty Pharmacy Only Must use CenterWell Specialty Pharmacy CenterWell Resources Provider Portal
Prescriber Requirement Hematologist or specialist preferred Plan policy documents Humana Guidelines
30-Day Supply Limit Initial fills limited to 30 days Medicare Part D regulations CMS Standards

What You'll Need:

  • Humana member ID card
  • Complete diagnosis and ICD-10 codes for hemophilia B
  • Documentation of previous factor IX therapies (if any)
  • Current weight and dosing calculations
  • Prescriber DEA number and contact information

Prior Authorization Forms and Requirements

Humana requires specific documentation for Alprolix prior authorization. The key is submitting complete clinical information upfront to avoid delays.

Required Forms:

  • Prior Authorization for Professionally Administered Drugs - Download from Humana Provider Portal
  • Clinical documentation including diagnosis, treatment history, and medical necessity justification

Medical Necessity Criteria: Your prescriber must document:

  1. Confirmed hemophilia B diagnosis with factor IX deficiency
  2. Clinical rationale for Alprolix specifically (extended half-life benefits, dosing convenience, patient-specific factors)
  3. Prior therapy history if switching from another factor IX product
  4. Dosing regimen based on patient weight and bleeding phenotype
  5. Treatment goals (prophylaxis vs. on-demand therapy)
Clinician Corner: Include specific references to FDA labeling for Alprolix, which supports both on-demand treatment and prophylaxis at 50 IU/kg weekly or 100 IU/kg every 10 days. This helps establish medical necessity within approved indications.

Submission Portals and Methods

Humana offers multiple ways to submit prior authorization requests. Electronic submission through their provider portal is fastest, but fax remains widely used for complex cases.

Electronic Submission:

  • Provider Portal: provider.humana.com
  • Availity Essentials: For eligibility verification and some PA submissions
  • PromptPA: Electronic prior authorization tool for providers

Upload Requirements:

  • Clinical notes in PDF format
  • Lab results showing factor IX levels (if available)
  • Previous treatment records
  • Prescriber attestation letter

Account Setup: Providers need active Humana credentialing and portal access. New users should register through the provider portal and complete identity verification before submitting requests.

Fax Numbers and Mailing Addresses

For Alprolix and other factor concentrates, use Humana's specialized intake numbers:

Primary Fax Numbers:

  • Professionally Administered Drugs: 888-447-3430
  • Expedited/Urgent Requests: 888-200-7440
  • General Pharmacy PA: 855-681-8650 (not for factor concentrates)

Mailing Address:

Humana Medication Intake Team
P.O. Box 14601
Lexington, KY 40512

Cover Sheet Tips:

  • Include "URGENT - HEMOPHILIA FACTOR IX" for expedited processing
  • List member ID prominently
  • Include prescriber contact information for follow-up questions
  • Attach all supporting documentation in order

Specialty Pharmacy Network Setup

Alprolix must be dispensed through CenterWell Specialty Pharmacy, Humana's preferred specialty network partner.

Enrollment Process:

  1. Call CenterWell: 1-800-486-2668 (Mon-Fri 8 AM-11 PM, Sat 8 AM-6:30 PM ET)
  2. Provide Information: Member ID, prescriber details, shipping address
  3. Clinical Intake: Pharmacist will review diagnosis and dosing
  4. Coordinate Delivery: Cold-chain shipping directly to patient or clinic

Transfer from Another Pharmacy: CenterWell can coordinate prescription transfers, but you'll need:

  • Authorization from current pharmacy
  • Complete prescription and refill history
  • Any pending prior authorization approvals

Support Lines and Who to Call

For Members:

  • General Customer Service: 800-457-4708
  • Pharmacy Benefits: Number on your Humana ID card
  • Appeals and Exceptions: Humana Member Portal

For Providers:

  • Prior Authorization Status: 866-461-7273 (TTY: 711)
  • Clinical Review Team: 866-488-5995 (Medicare requests)
  • CenterWell Specialty: 1-800-486-2668

What to Ask When Calling:

  • Specific PA requirements for your plan type
  • Timeline for determination
  • Required documentation checklist
  • Appeal process if denied

New York State Appeal Rights and External Review

New York offers strong consumer protections for insurance denials, including hemophilia medications. If Humana denies coverage, you have multiple appeal options.

Internal Appeal Process:

  • Timeline: File within 65 days of denial notice
  • Method: Online portal or call customer service
  • Decision Time: 7 days for standard, 72 hours for expedited

New York External Review: If Humana's internal appeal is unsuccessful, you can request an independent external review through the New York State Department of Financial Services.

External Review Process:

  • Eligibility: After final internal denial
  • Timeline: Must file within 4 months of denial
  • Contact: 1-800-400-8882 or [email protected]
  • Address: NY DFS, 99 Washington Avenue, Box 177, Albany, NY 12210
  • Fax: 800-332-2729

Expedited External Review: For urgent cases where delay could seriously jeopardize health, decisions are made within 72 hours.

New York Resources:

From Our Advocates: We've seen New York external reviewers overturn denials for specialty hemophilia medications when the clinical documentation clearly shows medical necessity and failure of preferred alternatives. The key is submitting comprehensive medical records and current treatment guidelines that support the specific factor concentrate requested.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Non-preferred brand Medical necessity letter explaining why preferred alternatives are inappropriate Contraindications, side effects, or treatment failures with formulary options
Dosing above limits Clinical justification for higher/more frequent dosing Bleeding diary, trough levels, treatment response data
No specialist prescriber Transfer prescription to hematologist Referral to qualified specialist
Insufficient medical necessity Comprehensive clinical documentation Complete hemophilia history, severity assessment, treatment goals
Step therapy not completed Exception request or complete required trials Documentation of contraindications or prior failures

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic): Call Humana at 800-457-4708 to confirm PA requirements for your specific plan
  2. Gather Documentation (Clinic): Collect diagnosis codes, treatment history, and prescriber information
  3. Submit PA Request (Prescriber): Fax complete request to 888-447-3430 or submit via provider portal
  4. Follow Up (Clinic): Call 866-461-7273 after 3-5 business days to check status
  5. Coordinate Specialty Pharmacy (Patient): Contact CenterWell at 1-800-486-2668 once approved
  6. Appeal if Denied (Patient/Prescriber): File internal appeal within 65 days via member portal
  7. External Review (Patient): If internal appeal fails, contact NY DFS within 4 months at 1-800-400-8882

FAQ: Alprolix Coverage with Humana in New York

How long does Humana prior authorization take for Alprolix? Standard requests take 7-14 business days. Expedited requests for urgent medical needs are processed within 72 hours.

What if Alprolix is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. If denied, appeal through Humana's internal process, then New York's external review.

Can I get expedited approval for Alprolix? Yes, if your prescriber documents that delay would seriously jeopardize your health. Call 866-461-7273 to request expedited review.

Does step therapy apply to factor IX products? Some Humana plans require trial of preferred factor IX products first. Your hematologist can request an exception if you have contraindications or prior treatment failures.

What happens if I'm new to Humana and already taking Alprolix? New enrollees may receive up to a 90-day transition supply while PA is processed, but claims may be reviewed for medical necessity.

How much will Alprolix cost with Humana coverage? Costs vary by plan. With prior authorization, you'll typically pay your plan's specialty tier copay or coinsurance. Contact member services for specific cost-sharing details.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific authorization requests. Our platform analyzes denial letters and plan policies to draft targeted rebuttals that meet each insurer's specific requirements, saving time and improving approval rates for complex medications like factor concentrates.

Whether you're navigating Humana's prior authorization process or appealing a denial through New York's external review system, having the right documentation and understanding each step can make the difference between coverage and costly out-of-pocket expenses. Don't hesitate to use the resources and contact information provided above - Counterforce Health and New York's consumer advocacy programs are here to help ensure you get the hemophilia treatment you need.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or the New York State Department of Financial Services.

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