By Counterforce Health Team in Bavencio (avelumab) —

How to Get Bavencio (Avelumab) Covered by Humana in Texas: Complete Prior Authorization Guide

Quick Answer: Getting Bavencio Covered by Humana in Texas

Bavencio (avelumab) requires prior authorization from all Humana plans in Texas. Your oncologist submits documentation proving FDA-approved indication (Merkel cell carcinoma or urothelial carcinoma maintenance), prior platinum therapy history, and ECOG performance status 0-2. Standard approvals take 15 business days; expedited requests for urgent cases process within 72 hours. If denied, you have 60 days to appeal internally, then can request Texas external review within 4 months.

First step today: Call the number on your Humana card to verify Bavencio's formulary status and get the current PA form.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Clinical Criteria
  5. Cost Considerations
  6. Denials and Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy
  9. Troubleshooting Common Issues
  10. FAQ
  11. Glossary

Coverage Basics

Is Bavencio Covered by Humana?

Yes, but prior authorization is required for all Humana Medicare Advantage and commercial plans. Bavencio sits on specialty drug tiers requiring higher cost-sharing than standard medications.

Which Humana Plans Cover Bavencio?

All Humana plans that include prescription drug benefits cover Bavencio for FDA-approved indications:

  • Medicare Advantage (Part C)
  • Medicare Part D plans
  • Commercial employer plans
  • Medicaid managed care plans

Coverage is limited to two specific cancer types with documented clinical criteria.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify coverage (Patient/Caregiver): Call Humana member services using the number on your insurance card
  2. Gather documentation (Oncologist's office): Pathology reports, staging scans, prior treatment records, lab results
  3. Complete PA request (Oncologist): Submit through Humana Provider Portal or fax to 1-888-790-9999
  4. Include medical necessity letter (Oncologist): Document FDA indication, NCCN guidelines, clinical rationale
  5. Track submission (Patient/Clinic): Standard decisions within 15 business days, expedited within 72 hours
  6. Follow up (Patient): Call Humana if no response by expected timeline
  7. Begin treatment (Clinic): Once approved, coordinate with specialty pharmacy for drug delivery

Who Submits the Prior Authorization?

Your oncologist or their staff submits the PA request. Patients cannot submit directly, but you can track status by calling Humana member services.

Timing and Deadlines

How Long Does Approval Take?

  • Standard requests: 15 business days from complete submission
  • Expedited requests: 72 hours when delay could jeopardize health
  • Incomplete submissions: Additional 14 days once missing information provided

When to Request Expedited Review

Request expedited processing if:

  • Cancer progression is rapid
  • Treatment delay could worsen prognosis
  • Current therapy is failing and immediate switch needed

Your oncologist must document medical urgency in the PA request.

Clinical Criteria

Coverage Requirements at a Glance

Requirement Merkel Cell Carcinoma Urothelial Carcinoma
Staging Metastatic disease Locally advanced or metastatic
Prior therapy None required Must complete first-line platinum chemotherapy
Disease status Confirmed diagnosis Stable disease or response to platinum
Performance status ECOG 0-2 ECOG 0-2
Timing Any time after diagnosis Within 4-10 weeks of last platinum dose

Required Documentation

Your oncologist must provide:

  • Pathology report confirming diagnosis
  • Staging scans (CT, MRI, or PET) showing disease extent
  • Prior treatment history with dates, doses, and outcomes
  • Current lab values (CBC, CMP, liver function tests)
  • ECOG performance status assessment
  • Medical necessity letter citing FDA approval and NCCN guidelines
Clinician Corner: The medical necessity letter should reference specific NCCN Guidelines categories and explain why Bavencio is appropriate for this patient's clinical scenario. Include any contraindications to alternative therapies.

Cost Considerations

What Will You Pay?

Bavencio typically requires 25-33% coinsurance rather than flat copays due to specialty tier placement. Without insurance approval, each infusion can exceed $10,000.

Financial Support Options

CoverOne Patient Assistance Program:

  • Copay assistance up to $30,000 per year for privately insured patients
  • Free drug program for uninsured/underinsured patients meeting income criteria
  • Contact: 844-826-8371

Important: Enroll in patient assistance before starting treatment—benefits aren't applied retroactively.

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Fix
Missing prior platinum therapy documentation Submit chemotherapy records with dates and cycles completed
ECOG performance status not documented Have oncologist assess and document current functional status
Insufficient staging information Provide recent imaging reports showing disease extent
Use outside FDA indication Confirm diagnosis matches approved indications exactly
Missing medical necessity rationale Submit detailed letter explaining clinical need

Texas Appeals Process

Internal Appeal (Level 1):

  • File within 60 days of denial notice
  • Humana has 30 days for standard review, 72 hours for expedited
  • Submit additional clinical documentation supporting medical necessity

External Review (Level 2):

  • Available within 4 months of final internal denial
  • Conducted by Independent Review Organization (IRO) contracted through Texas Department of Insurance
  • IRO decision is binding on Humana
  • Standard external reviews completed within 20 days, urgent cases within 5 days

How to File Appeals:

  • Call Humana member services for appeal forms
  • Submit written appeal with supporting documentation
  • Request peer-to-peer review with Humana's medical director
From our advocates: We've seen denials overturned when oncologists include recent imaging showing disease progression or stability, along with detailed explanations of why the patient doesn't meet criteria for alternative checkpoint inhibitors. The key is matching your clinical documentation exactly to Humana's published criteria.

Renewal Requirements

When to Re-authorize

Bavencio approvals typically last 12 months. Your oncologist should submit renewal requests 30-60 days before expiration to avoid treatment interruptions.

What Changes for Renewals

Renewal requests require:

  • Updated imaging showing treatment response or stable disease
  • Current performance status assessment
  • Documentation of treatment tolerance
  • Continued medical necessity rationale

Treatment can continue during renewal review if submitted before expiration.

Specialty Pharmacy

Why Was My Prescription Transferred?

Some Humana plans require specialty drugs be dispensed through CenterWell Specialty Pharmacy rather than your usual pharmacy. This ensures proper handling of expensive biologics and provides additional patient support services.

Specialty Pharmacy Benefits

  • Temperature-controlled shipping
  • Injection training and support
  • Prior authorization assistance
  • Financial counseling services

Confirm specialty pharmacy requirements when verifying coverage to avoid delays.

Troubleshooting Common Issues

Portal Problems

If Humana's provider portal is down:

  • Fax PA requests to 1-888-790-9999
  • Call provider services at 866-421-5663
  • Keep fax confirmation receipts for your records

Missing Forms

Current PA forms are available through the Humana Provider Portal. If you can't access forms:

  • Call Humana provider services
  • Request forms be faxed to your clinic
  • Use previous year's forms with updated date if current forms unavailable

Status Check Delays

If you haven't received a decision within expected timelines:

  • Call Humana member services with your PA reference number
  • Request escalation to supervisor if standard timeline exceeded
  • Document all conversations with dates and representative names

When dealing with insurance coverage challenges, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to craft point-by-point rebuttals aligned with payer requirements.

FAQ

How long does Humana prior authorization take in Texas? Standard PA decisions take 15 business days. Expedited requests for urgent medical situations are completed within 72 hours.

What if Bavencio is non-formulary on my plan? Request a formulary exception with medical necessity documentation explaining why formulary alternatives are inappropriate for your cancer type.

Can I request an expedited appeal? Yes, if treatment delay could seriously jeopardize your health. Your oncologist must document medical urgency.

Does step therapy apply to Bavencio? For urothelial carcinoma, you must complete first-line platinum-based chemotherapy before Bavencio approval. Merkel cell carcinoma has no step therapy requirements.

What happens if my appeal is denied? You can request external review through Texas Department of Insurance within 4 months. The independent reviewer's decision is binding on Humana.

How do I check my appeal status? Call Humana member services with your appeal reference number. Representatives can provide status updates and expected decision dates.

Glossary

Prior Authorization (PA): Insurance approval required before certain medications are covered

Quantity Limit (QL): Restrictions on how much medication is covered per time period

Step Therapy (ST): Requirement to try specific medications before others are covered

Peer-to-Peer (P2P): Phone consultation between your doctor and insurance medical director

Letter of Medical Necessity (LMN): Doctor's written explanation of why specific treatment is needed

ECOG Performance Status: Scale measuring how cancer affects daily functioning (0=normal, 4=bedridden)

Formulary: List of medications covered by your insurance plan

External Review: Independent evaluation of insurance denials by third-party medical experts

IRO: Independent Review Organization contracted by Texas to review insurance appeals

For additional help with insurance appeals in Texas, contact the Texas Department of Insurance consumer hotline at 1-800-252-3439 or the Office of Public Insurance Counsel at 1-877-611-6742. Counterforce Health also provides specialized assistance turning insurance denials into successful appeals through evidence-based documentation and payer-specific workflows.

Sources & Further Reading

This article provides educational information and should not be considered medical advice. Always consult your healthcare provider about treatment decisions and insurance coverage options specific to your situation.

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