By Counterforce Health Team in Arcalyst (rilonacept) —

How to Get Arcalyst (Rilonacept) Covered by Humana in Virginia: Prior Authorization Forms, Appeal Process, and Resources

Answer Box: Getting Arcalyst (Rilonacept) Covered by Humana in Virginia

Arcalyst (rilonacept) requires prior authorization from Humana for CAPS, DIRA, and recurrent pericarditis. Your fastest path: Have your prescriber submit a PA request with medical necessity documentation through Humana's provider portal or fax to 1-888-447 (verify current number). If denied, you have 65 days to appeal and can request external review through Virginia's Bureau of Insurance using Form 216-A. Start today: Call Humana member services (number on your ID card) to confirm PA requirements and get the current submission process.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Specialty Pharmacy Enrollment
  5. Appeals Process: Internal and External
  6. Common Denial Reasons and Solutions
  7. Virginia State Resources and Support
  8. Costs and Financial Assistance
  9. FAQ

Start Here: Verify Your Plan and Coverage

Before submitting any paperwork, confirm your specific Humana plan type and Arcalyst's status:

Call Humana member services (phone number on your insurance card) and ask:

  • "Does my plan require prior authorization for Arcalyst (rilonacept), NDC code or J-code J2793?"
  • "Is Arcalyst on my formulary, and what tier?"
  • "What documentation does my doctor need to submit?"

Key plan types in Virginia:

Tip: Have your member ID, prescriber's name, and diagnosis ready when calling. This saves time and ensures accurate information.

Prior Authorization Forms and Requirements

Medical Necessity Documentation

Your prescriber must provide comprehensive documentation including:

For Recurrent Pericarditis:

  • Confirmed diagnosis with ≥2 prior episodes
  • Documentation of symptom-free interval (4-6 weeks) followed by relapse
  • Failed trials of NSAIDs, colchicine, and/or corticosteroids
  • Elevated inflammatory markers (CRP, ESR)
  • Cardiac MRI or CT showing pericardial inflammation

For CAPS/DIRA:

  • Genetic testing confirmation (NLRP3 mutations for CAPS, IL1RN for DIRA)
  • Clinical features: recurrent fever, rash, serositis
  • Elevated inflammatory markers during flares
  • Failed conventional treatments

Submission Requirements

Document Type Required For Notes
Prescriber letter All requests Must include medical necessity rationale
Lab results All requests CRP, ESR, genetic testing if applicable
Imaging reports Pericarditis cases Cardiac MRI preferred, CT acceptable
Prior therapy documentation All requests Medication names, doses, duration, outcomes
ICD-10 codes All requests I30.1/I30.8 (pericarditis), M04.- (CAPS)

Submission Portals and Methods

Online Submission

Fax Submission

Professional administered drugs fax: 1-888-447 (verify current number with Humana)

Note: Always confirm current fax numbers and submission requirements, as these can change. Call Humana's provider line for the most up-to-date information.

Required Account Setup

Providers need Availity credentials or direct Humana provider portal access to submit online requests.

Specialty Pharmacy Enrollment

Arcalyst is typically dispensed through specialty pharmacy due to its complex handling requirements and high cost.

CenterWell Specialty Pharmacy Process

  1. Enrollment: Contact CenterWell Specialty Pharmacy after PA approval
  2. Prescription transfer: Cannot transfer controlled substances - prescriber must send new prescription directly
  3. Delivery timeline: 3-5 business days after approval
  4. Clinical support: Included with specialty pharmacy services

Important limitation: Arcalyst cannot be transferred through standard procedures due to controlled substance regulations. Your prescriber must send a fresh prescription to CenterWell.

Patient Access Programs

Enroll in Kiniksa OneConnect™ program for additional support:

  • Benefits verification assistance
  • Prior authorization support
  • Financial assistance coordination
  • Clinical education resources

Appeals Process: Internal and External

Humana Internal Appeals

Timeline: 65 days from denial notice to file appeal

Medicare Advantage/Part D:

  • Standard decisions: 7 calendar days (Part D), 30 days (Part C pre-service)
  • Expedited appeals: 72 hours if delay could harm health
  • Submit via: Phone (800-867-6601), online portal, or mail

Required documents:

Virginia External Review

If Humana denies your internal appeal, Virginia law provides independent external review.

Filing requirements:

  • Submit Form 216-A within 120 days of final denial
  • Include Humana's final adverse determination letter
  • Provide comprehensive medical records

Review timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (use Form 216-C for physician certification)

Contact for guidance: Virginia Managed Care Ombudsman at 1-877-310-6560 (free assistance)

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
"Not medically necessary" Provide stronger clinical rationale Updated prescriber letter, current labs, imaging
"Experimental/investigational" Cite FDA approval for your diagnosis FDA label, peer-reviewed studies
Step therapy not met Document prior therapy failures Medication trial log, adverse event reports
Non-formulary status Request formulary exception Medical necessity letter, alternative drug failures
Quantity/frequency limits Justify dosing per FDA label Weight-based calculations, FDA prescribing info
From our advocates: We've seen success when prescribers emphasize the "inflammatory phenotype" with elevated CRP levels during pericarditis flares, as this aligns with payer policies requiring objective evidence of active inflammation. Including cardiac MRI findings strengthens the case significantly.

Virginia State Resources and Support

State Corporation Commission Bureau of Insurance

Consumer Services: 1-877-310-6560

  • Free guidance on appeal rights
  • External review process assistance
  • Complaint filing for improper denials

External Review Forms:

  • Form 216-A: External Review Request
  • Form 216-C: Expedited Review Physician Certification

Additional Support Organizations

Virginia Poverty Law Center Health Assistance

  • Legal help for insurance appeals
  • Medicaid and ACA marketplace issues
  • Free consultation services

Counterforce Health provides specialized support for complex prior authorization cases, helping patients and providers navigate insurance denials with evidence-based appeals. Their platform analyzes denial letters and creates targeted rebuttals using payer-specific policies and clinical guidelines. Learn more about their services.

Costs and Financial Assistance

Manufacturer Support

Kiniksa OneConnect™ Patient Access Program:

  • Copay assistance for eligible patients
  • Benefits investigation
  • Prior authorization support
  • Free drug programs for qualifying patients

Virginia-Specific Resources

  • Virginia Medicaid: Covers Arcalyst with PA approval
  • State pharmaceutical assistance programs: Contact Virginia Department of Social Services
  • Charitable foundations: Patient Access Network Foundation, others (verify eligibility)

Cash pricing: Several thousand dollars per 220mg kit (varies by pharmacy)

FAQ

How long does Humana prior authorization take in Virginia? Standard PA decisions: 7 days for Part D, up to 30 days for Part C. Expedited requests: 72 hours if medically urgent.

What if Arcalyst is not on my Humana formulary? Request a formulary exception with medical necessity documentation. Your prescriber must explain why formulary alternatives are inappropriate.

Can I request expedited appeals in Virginia? Yes. If delay could harm your health, request expedited review through Humana (72 hours) and Virginia external review (72 hours for urgent cases).

Does step therapy apply to Arcalyst? Typically yes. Document failures/intolerances of NSAIDs, colchicine, and corticosteroids for pericarditis cases.

What counts as medical necessity for Arcalyst? FDA-approved diagnosis (CAPS, DIRA, recurrent pericarditis), failed conventional therapies, elevated inflammatory markers, and specialist prescription.

How do I transfer my prescription to CenterWell Specialty Pharmacy? You cannot transfer Arcalyst prescriptions. Your prescriber must send a new prescription directly to CenterWell due to controlled substance regulations.

What if my employer plan is self-funded? Virginia external review may apply if your employer opted in. If not, federal external review through HHS may be available. Contact the Bureau of Insurance for guidance.

Can I appeal if I live in Virginia but have coverage from another state? If your plan is Virginia-issued or opted into Virginia's external review process, yes. Contact the Bureau of Insurance at 1-877-310-6560 to verify eligibility.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For questions about Virginia insurance regulations, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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