By Counterforce Health Team in Busulfex (busulfan injection) —

How to Get Busulfex (Busulfan Injection) Covered by Humana in Ohio: Forms, Appeals, and Provider Contacts

Answer Box: Getting Busulfex Covered by Humana in Ohio

Busulfex (busulfan injection) typically requires prior authorization from Humana as a high-cost oncology infusion drug billed under the medical benefit (HCPCS J0594). For Ohio members, submit requests through Humana's professionally administered drug PA process. First step today: Verify the member's plan type (Medicare Advantage vs. commercial) using Humana's Prior Authorization Search Tool, then download the correct PA form from the provider portal. Standard decisions take 30 days for medical benefits; expedited review available within 72 hours if delay risks serious harm. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance.

Table of Contents

  1. Verify Your Plan and Check PA Requirements
  2. Forms: Prior Authorization and Exception Requests
  3. Submission Portals and Electronic Options
  4. Fax Numbers and Mail Addresses
  5. Specialty Pharmacy Coordination
  6. Support Phone Lines and Contact Information
  7. Ohio External Review and Regulatory Help
  8. Common Denial Reasons and How to Fix Them
  9. Medical Necessity Letter Checklist
  10. FAQ: Busulfex Coverage in Ohio

I. Verify Your Plan and Check PA Requirements

Start here to confirm coverage rules for your specific Humana product:

  1. Identify plan type: Medicare Advantage, commercial, or Medicaid
  2. Use Humana's Prior Authorization Search Tool:
    • Select State: Ohio
    • Choose Plan: Medicare (for Medicare Advantage) or Commercial
    • Search by drug name "busulfan" or HCPCS code "J0594"
  3. Confirm benefit category: Busulfex is typically billed under the medical benefit (not Part D pharmacy) for transplant conditioning
Note: Humana requires PA for most high-cost oncology infusions, including chemotherapy agents used in transplant conditioning. Verify current requirements.

II. Forms: Prior Authorization and Exception Requests

For Professionally Administered Busulfex (IV infusion)

Primary Form: "Prior Authorization for Professionally Administered Drugs"

  • Where to find: Humana Provider Portal - Pharmacy Resources
  • Use for: J0594 busulfan injection given in clinic/hospital
  • Required sections: Member info, provider NPI, diagnosis codes, clinical justification, planned treatment schedule

For Medicare Advantage Members

Coverage Determination Form: "Request for Medicare Prescription Drug Coverage Determination"

  • When to use: If busulfan is processed under Part D (rare for IV conditioning)
  • Available at: Humana Member Forms
  • Timeline: 72 hours standard, 24 hours expedited

Appeal Forms (if PA denied)

Internal Appeal: "Appeal, Complaint or Grievance" form

  • Deadline: 65 days from denial notice for Medicare; varies for commercial
  • Required: Original denial letter, additional clinical documentation
  • Access: Humana Exceptions and Appeals

III. Submission Portals and Electronic Options

Electronic Prior Authorization

CoverMyMeds: Primary electronic PA platform

  • Access: CoverMyMeds.com
  • Select: Appropriate Humana plan and busulfan/J0594
  • Upload: Clinical notes, labs, transplant evaluation

Humana Provider Portal: Direct submission option

  • Login: Provider.humana.com
  • Navigate: Coverage & Claims → Prior Authorizations
  • Attach: Complete clinical documentation in single submission

Required Clinical Documentation

Upload the following with your PA request:

  • Transplant consultation notes
  • Pathology reports and staging
  • Prior therapy history and outcomes
  • Recent labs (CBC, liver panel, cardiac/pulmonary function)
  • Planned conditioning protocol
  • Medical necessity letter

IV. Fax Numbers and Mail Addresses

Prior Authorization Fax

Medication Intake Team (MIT): 855-227-0677

  • Use for: Professionally administered drug PA forms
  • Include: Cover sheet with member ID, provider NPI, urgency level
  • Confirmation: Call Provider Services to confirm receipt

Provider Services Phone

Main Line: 877-856-5707 (TTY: 711)

  • Hours: Monday–Friday, 7 a.m. to 8 p.m. Eastern
  • Use for: PA status, clinical review requests, peer-to-peer scheduling

Mail Address (if required)

Humana Provider Services P.O. Box 14601 Lexington, KY 40512

Tip: Always fax rather than mail for time-sensitive requests. Include a cover sheet noting "URGENT - TRANSPLANT CONDITIONING" if applicable.

V. Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy

Primary specialty pharmacy: CenterWell (Humana's preferred)

  • Provider line: Contact through Humana Provider Services
  • E-prescribing: Available for oral busulfan
  • Coordination: Can assist with PA submission for specialty drugs

Transfer Instructions

  1. Verify coverage: Confirm busulfan is covered through specialty benefit
  2. Obtain PA: Complete prior authorization before transfer
  3. Coordinate timing: Ensure delivery aligns with transplant schedule
  4. Monitor: Track shipment and confirm receipt at treatment facility

VI. Support Phone Lines and Contact Information

Member Services

Phone: 877-856-5702

  • Hours: Monday–Friday, 7 a.m. to 8 p.m. Eastern
  • Services: Eligibility verification, benefit questions, PA status

Provider Support

Provider Services: 877-856-5707

  • Clinical reviews: Request peer-to-peer consultation
  • PA assistance: Help with form completion and submission
  • Expedited requests: Process urgent authorizations

24-Hour Resources

Nurse Advice Line: 866-376-4827 (24/7/365)

  • Use for: Clinical questions, urgent coverage issues

Fraud/Waste Hotline: 800-614-4126 (24/7)

VII. Ohio External Review and Regulatory Help

Ohio Department of Insurance External Review

When to use: After exhausting Humana's internal appeals Deadline: 180 days from final adverse determination Form: "Ohio Department of Insurance – External Review Request Form"

How to request:

  1. Contact Humana to initiate external review process
  2. Complete ODI External Review Request Form
  3. Submit within 180-day deadline
  4. Include all supporting clinical documentation

ODI Consumer Hotline: 800-686-1526

  • Services: Help with external review forms, process guidance
  • Hours: Business hours for consumer assistance

External Review Process

Standard review: 30 days for decision Expedited review: 72 hours for urgent cases Decision binding: Humana must comply if overturned

Learn more about Ohio external review

VIII. Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Cite FDA approval, NCCN guidelines FDA label, transplant protocols, medical necessity letter
"Alternative treatments available" Document prior therapy failures Chronologic treatment history with outcomes
"Investigational/experimental" Reference standard conditioning protocols NCCN guidelines, institutional protocols
"Non-network provider" Request network exception Rationale for specific transplant center
"Insufficient documentation" Submit complete clinical packet All required forms, labs, notes in one submission

Scripts for Common Situations

Requesting expedited review: "This is for busulfan conditioning prior to hematopoietic stem cell transplant. Delay in approval may jeopardize the transplant window and seriously endanger the patient's life. We request expedited review under the 72-hour timeline."

Peer-to-peer request: "We're requesting a peer-to-peer clinical review for busulfan (J0594) prior authorization. The treating hematologist is available to discuss the medical necessity and urgency of this transplant conditioning regimen."

IX. Medical Necessity Letter Checklist

Required Elements for Busulfex PA

Patient Information:

  • Diagnosis with ICD-10 codes
  • Disease stage and risk stratification
  • Transplant type (autologous vs. allogeneic)

Clinical Rationale:

  • FDA-approved indication for busulfan in conditioning
  • Why this specific regimen is optimal
  • Contraindications to alternative conditioning

Prior Therapies:

  • Previous treatments attempted
  • Outcomes (response, toxicity, failure)
  • Reason for transplant referral

Safety Monitoring:

  • Baseline organ function assessment
  • Planned therapeutic drug monitoring
  • VOD prevention protocol

Supporting Evidence:

  • Reference to NCCN guidelines
  • Institutional transplant protocols
  • Published outcomes data (if available)
From our advocates: In our experience helping patients navigate complex oncology approvals, the most successful busulfan authorizations include a clear timeline showing disease progression despite standard therapies, explicit connection to FDA-approved indications, and detailed transplant center protocols. These comprehensive submissions often receive approval on first review.

X. FAQ: Busulfex Coverage in Ohio

How long does Humana PA take for Busulfex in Ohio? Standard medical benefit PA decisions: 30 days. Expedited review: 72 hours if delay risks serious harm. Part D determinations (rare for IV busulfan): 72 hours standard, 24 hours expedited.

What if Busulfex is non-formulary? For IV busulfan (J0594), coverage is typically under medical benefit, not formulary. If oral busulfan is non-formulary, request a formulary exception with prescriber attestation that covered alternatives would be less effective or cause adverse effects.

Can I request an expedited appeal? Yes. If transplant timing is critical or delay would seriously jeopardize health, request expedited review. Include statement from treating physician about urgency and potential consequences of delay.

Does step therapy apply to Busulfex? Step therapy requirements vary by plan. For transplant conditioning, emphasis should be on medical necessity and appropriateness of the specific regimen rather than trying less expensive alternatives first.

What if my transplant center is out-of-network? Request a network exception, documenting why this specific center is required (specialized expertise, donor coordination, clinical trial participation). Include outcomes data if available.

How do I check my appeal status? Call Humana Member Services at 877-856-5702 with your member ID and appeal reference number. You can also check status through the member portal online.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Busulfex. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific payer requirements. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process with greater success rates and reduced administrative burden.

When dealing with high-stakes medications like busulfan for transplant conditioning, having expert support can make the difference between approval and delay. Counterforce Health provides the clinical and regulatory expertise needed to build compelling cases for coverage, especially when standard PA submissions have been unsuccessful.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services at 800-686-1526.

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