By Counterforce Health Team in Berinert (C1-esterase inhibitor, IV) —

How to Get Berinert (C1-esterase inhibitor, IV) Covered by Humana in Washington: Complete Prior Authorization Guide

Answer Box: Getting Berinert Covered by Humana in Washington

Humana requires prior authorization for Berinert (C1-esterase inhibitor, IV) for hereditary angioedema treatment. The fastest path to approval: (1) Submit PA request through CoverMyMeds with complete HAE diagnosis documentation, (2) Include evidence of failed alternative therapies or contraindications, and (3) Use CenterWell Specialty Pharmacy for distribution. Start today by gathering your HAE diagnosis records and prior treatment history—most approvals take 7-14 days with complete documentation.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Information
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & Prevention
  10. Appeals Process in Washington
  11. Cost Assistance Options
  12. FAQ

Who Should Use This Guide

This guide is for Washington residents with Humana Medicare Advantage or commercial plans who need Berinert (C1-esterase inhibitor, IV) for hereditary angioedema (HAE) treatment. You'll find this most helpful if you're facing:

  • Initial prior authorization requirements
  • Recent coverage denials
  • Confusion about Humana's specialty pharmacy network
  • Questions about Washington's appeal rights

Expected outcome: With complete documentation, most Berinert requests are approved within 7-14 business days. Humana's PA denial rate for Medicare Advantage is approximately 3.5%—among the lowest of major insurers—but denials often occur due to incomplete documentation rather than medical necessity disputes.

Member & Plan Basics

Coverage Requirements

Requirement Details Verification
Active Coverage Current Humana enrollment Check member portal or call customer service
Prior Authorization Required for all Berinert requests Humana PA requirements
Plan Type Medicare Advantage, Part D, or Commercial Review your insurance card
Deductible Status May apply before coverage begins Check your plan documents
Note: Self-funded employer plans may have different requirements. Contact your HR department to confirm if standard Humana policies apply.

Clinical Criteria Requirements

FDA-Approved Indication

Berinert is approved for acute HAE attacks only—not prophylaxis. Coverage requests for preventive use are typically denied.

Step Therapy Requirements

Most Humana plans require documentation of:

  • Failed trials of preferred alternatives (icatibant/Firazyr, ecallantide/Kalbitor)
  • Contraindications to first-line therapies (e.g., rabbit allergy preventing Ruconest use)
  • Inadequate response to other C1-inhibitor products

Dosing Parameters

  • Standard dose: 20 IU/kg IV per acute attack
  • Frequency limits: Typically 4 attacks per 4-week period
  • Administration: Hospital outpatient, infusion center, or trained self-administration

Coding and Billing Information

Required Codes

Code Type Code Description
HCPCS J-code J0597 C1-esterase inhibitor (Berinert), 10 units
Primary ICD-10 D84.1 Hereditary angioedema
Secondary ICD-10 T78.3XXA Angioedema, initial encounter (for acute attacks)

NDC Codes

  • Vial: 63833-0835-xx
  • Kit: 63833-0825-xx
Tip: Always verify current NDC codes with your specialty pharmacy, as manufacturers occasionally update packaging.

Documentation Packet Essentials

Medical Necessity Letter Components

Your prescriber's letter should include:

  1. Patient demographics and insurance information
  2. HAE diagnosis confirmation with supporting lab values (C4, C1-INH levels)
  3. Attack history including frequency, severity, and emergency department visits
  4. Prior therapy documentation:
    • Medications tried (icatibant, ecallantide, other C1-inhibitors)
    • Dates of treatment
    • Outcomes (inadequate response, adverse effects, contraindications)
  5. Clinical rationale for Berinert specifically
  6. Dosing plan (20 IU/kg per attack)
  7. Administration setting (clinic vs. self-administration plan)

Required Attachments

  • Recent clinic notes documenting HAE diagnosis
  • Laboratory results (C4, C1-INH functional/antigenic levels)
  • Records of prior treatment failures or contraindications
  • Emergency department records for severe attacks (if applicable)

Submission Process

Electronic Submission (Preferred)

  1. Access CoverMyMeds: Visit www.covermymeds.com/epa/humana
  2. Complete PA form with prescriber NPI and member information
  3. Upload documentation (medical necessity letter and attachments)
  4. Submit electronically for fastest processing

Alternative Submission Methods

  • Fax: 1-877-486-2621 (standard PA requests)
  • Phone support: 1-800-555-2546 (Mon-Fri, 8 AM-6 PM local time)
Important: Always request a confirmation number and keep records of submission dates.

Specialty Pharmacy Requirements

Preferred Network

CenterWell Specialty Pharmacy (formerly Humana Specialty Pharmacy) is Humana's preferred distributor for Berinert. Using non-preferred pharmacies may result in:

  • Higher out-of-pocket costs
  • Coverage denials
  • Additional authorization requirements

Pharmacy Coordination

  1. Verify network status before sending prescriptions
  2. Confirm PA approval is on file before dispensing
  3. Coordinate delivery for home administration patients

Find network pharmacies here

After Submission: What to Expect

Timeline

  • Standard review: 7-14 business days
  • Expedited review: 72 hours (for urgent medical situations)
  • Appeal decisions: 30 days (internal), additional 30 days (external review)

Status Tracking

  • Online portal: Check status through Humana member portal
  • Phone: Call medication intake team at 1-800-555-2546
  • Confirmation: Keep all reference numbers for follow-up

Common Denial Reasons & Prevention

Denial Reason Prevention Strategy
Prophylaxis request Clearly document acute treatment indication
Incomplete documentation Include all required attachments and clinical notes
Missing step therapy Document failed alternatives or contraindications
Quantity limits exceeded Justify dosing with weight-based calculations
Site of care restrictions Confirm approved administration settings

From Our Advocates

We've seen many HAE patients initially denied for Berinert because their medical necessity letter didn't clearly document prior treatment failures. The key is being specific—include exact dates, medications tried, and why each alternative didn't work. This level of detail often turns a denial into an approval on the first submission.

Appeals Process in Washington

Washington State provides robust consumer protections for insurance denials. Here's your step-by-step appeals pathway:

Internal Appeals (Required First Step)

  1. Submit within 65 days of denial notice
  2. Include new clinical information if available
  3. Request expedited review if medically urgent
  4. Fax appeals to: 1-800-949-2961

External Review (Independent Review)

If your internal appeal is denied, Washington law gives you the right to an Independent Review Organization (IRO) review:

  1. Timeline: 180 days from final internal denial to request external review
  2. Process: Submit request to Washington Office of Insurance Commissioner (OIC)
  3. Decision: IRO must decide within 30 days (72 hours for expedited)
  4. Binding: IRO decisions are binding on Humana

Washington State Resources

Washington Advantage: The state's external review process often includes HAE specialists from major medical centers, giving you access to expert clinical opinions that may override insurer denials.

Cost Assistance Options

Manufacturer Support

Additional Resources

  • HAE patient organizations: Often provide grant programs and advocacy support
  • Washington Apple Health: Medicaid coverage for eligible residents
  • Counterforce Health: Helps patients navigate insurance denials and create targeted appeals. Their platform analyzes denial letters and plan policies to draft evidence-backed rebuttals that align with your specific Humana plan requirements. Learn more about their services.

FAQ

How long does Humana prior authorization take for Berinert in Washington? Standard PA requests take 7-14 business days. Expedited requests (for urgent medical situations) are processed within 72 hours.

What if Berinert is non-formulary on my Humana plan? You can request a formulary exception through the same PA process. Include strong clinical justification for why formulary alternatives aren't appropriate.

Can I request an expedited appeal in Washington? Yes, both Humana and Washington State allow expedited appeals when your health could be in serious jeopardy. These are typically decided within 72 hours.

Does step therapy apply if I've tried medications outside Washington? Yes, documentation of prior treatment failures from any location counts toward step therapy requirements, as long as you have proper medical records.

What happens if my appeal is denied? In Washington, you have the right to external review by an Independent Review Organization. This decision is binding on Humana and often includes HAE specialists.

How do I know if I need a peer-to-peer review? If your initial PA is denied for medical necessity reasons, request a peer-to-peer review where your prescriber can discuss the case directly with a Humana medical director.

Printable Checklist

Before You Submit:

  • Current insurance card and member ID
  • HAE diagnosis documentation with lab values
  • Records of prior treatment failures/contraindications
  • Weight-based dosing calculations (20 IU/kg)
  • Medical necessity letter from prescriber
  • Confirmation of CenterWell Specialty Pharmacy network status

After Submission:

  • Confirmation number recorded
  • Follow-up call scheduled for 7-10 business days
  • Appeal deadline noted (65 days from any denial)
  • Washington external review rights understood

When insurance denials threaten access to critical HAE treatment, Counterforce Health provides specialized support to turn denials into approvals. Their platform helps patients and clinicians create targeted, evidence-backed appeals that address specific payer requirements and increase approval rates.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions.

Sources & Further Reading:

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