By Counterforce Health Team in Cerezyme (imiglucerase) —

How to Get Cerezyme (Imiglucerase) Covered by Humana in Washington: Complete Guide with Forms and Appeals

Answer Box: Getting Cerezyme Covered by Humana in Washington

Cerezyme (imiglucerase) requires prior authorization from Humana Medicare Advantage plans. Your fastest path to approval: 1) Confirm Type 1 Gaucher disease diagnosis with enzyme testing and genetic analysis, 2) Submit complete prior authorization request through Humana's provider portal with clinical documentation, and 3) If denied, file internal appeal within 65 days, then external review through Washington's Independent Review Organization (IRO) system. Start today by gathering your diagnosis confirmation, treatment history, and insurance information, then contact your prescriber to initiate the prior authorization process.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Official Source
Prior Authorization Mandatory approval before dispensing Humana PA Search Tool Humana Provider Portal
Formulary Status Nonpreferred (Elelyso is preferred) Humana Drug Lists Humana Formulary
Diagnosis Required Type 1 Gaucher disease confirmed Medical records with enzyme/genetic testing FDA Label Requirements
Appeal Deadline 65 days from denial notice Member denial letter Medicare Appeals Guide
External Review Available through Washington IRO WA Insurance Commissioner Washington State Law

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis (Patient + Provider)

Ensure you have documented Type 1 Gaucher disease with both enzyme testing (beta-glucosidase leukocyte assay showing deficiency) and genetic testing (two pathogenic mutations in the GBA gene). Most insurers require both tests for Cerezyme authorization.

Timeline: 1-2 weeks if testing needed
Who does it: Your specialist orders tests; lab processes results

2. Check Humana's Current Requirements (Provider)

Your doctor should use Humana's Prior Authorization Search Tool to download the current Cerezyme-specific form and requirements.

Timeline: Same day
Submit via: Humana provider portal, fax to 877-486-2621, or phone

3. Gather Clinical Documentation (Provider + Patient)

Compile your complete medical history including:

  • Confirmed Type 1 Gaucher disease diagnosis
  • Baseline biomarker and clinical data
  • Previous treatment attempts (if applicable)
  • Prescribed dosage and treatment plan (typically 30-60 units/kg every 2 weeks per FDA labeling)

Timeline: 3-5 business days
Who does it: Medical records department with provider oversight

4. Submit Prior Authorization Request (Provider)

Complete submission through Humana's electronic portal for fastest processing. Include all required clinical documentation to avoid delays.

Timeline: 1 business day for complete electronic submissions
Expected decision: Within 30 days standard, 72 hours if expedited

5. Monitor Decision and Prepare for Potential Appeal (Patient + Provider)

Track your request status and prepare appeal documentation if denied. Humana's Medicare Advantage PA denial rate is approximately 3.5%, among the lowest of major insurers.

Timeline: Check status weekly
Next step: If denied, file internal appeal within 65 days

Required Documentation

For Initial Prior Authorization:

Clinical Requirements:

  • Type 1 Gaucher disease diagnosis confirmation
  • Enzyme assay results (beta-glucosidase deficiency)
  • Genetic testing results (GBA gene mutations)
  • Clinical evidence of disease severity
  • Treatment history and rationale

Administrative Requirements:

  • Completed Humana prior authorization form
  • Provider attestation of medical necessity
  • Prescribed dosing plan within FDA-approved range
Tip: Submit requests electronically through Humana's provider portal for fastest processing—typically decided within one business day for complete requests.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient diagnosis documentation Submit complete enzyme and genetic testing Lab reports showing GCase deficiency + GBA mutations
Dosing outside FDA label Provide clinical justification Medical necessity letter citing patient-specific factors
Preferred alternative not tried Request formulary exception Document why Elelyso (preferred) is inappropriate
Missing specialist evaluation Obtain metabolic/genetic specialist consultation Specialist evaluation and treatment recommendation
Incomplete prior therapy documentation Provide detailed treatment history Records of previous therapies, outcomes, side effects

Appeals Process in Washington

Internal Appeals (Level 1)

You have 65 days from your denial notice to file with Humana. Submit through the member portal or call the number on your ID card.

Required: Your appeal request, denial letter, supporting medical records Timeline: 30 days standard, 72 hours expedited Cost: No charge

External Review (Level 2+)

If Humana denies your internal appeal, you can request review by a Qualified Independent Contractor (QIC) - this is your external review by an organization independent from Humana.

Timeline: File within 65 days of Level 1 denial Process: Automatic referral to independent medical reviewers Binding: Decision is binding on Humana if overturned

Washington State Support

Contact Statewide Health Insurance Benefits Advisors (SHIBA) volunteers for free help navigating the appeals process. SHIBA can guide you through each level and help you understand your rights.

Phone: 1-800-562-6900 Services: Appeal guidance, rights explanation, form assistance

Patient Support and Cost Assistance

Manufacturer Programs

Sanofi, Cerezyme's manufacturer, offers patient support programs that may help with:

  • Prior authorization assistance
  • Appeals support
  • Financial assistance for eligible patients
  • Care coordination services

Contact Sanofi's patient support team directly for current program details and eligibility requirements.

Foundation and Grant Programs

Several rare disease foundations provide financial assistance for Gaucher disease treatments. Research current programs through organizations like the National Gaucher Foundation and rare disease advocacy groups.

Note: Assistance programs change frequently. Verify current eligibility and application processes directly with each organization.

When to Contact Washington State Regulators

If you've exhausted Humana's internal appeals process and need additional support, Washington's Office of the Insurance Commissioner provides consumer advocacy services.

Contact Washington OIC when:

  • Appeals process seems mishandled
  • Deadlines aren't being met by Humana
  • You need help understanding your rights
  • You want to file a complaint about coverage decisions

Washington OIC Consumer Advocacy: 1-800-562-6900 Services: Appeal guidance, complaint filing, regulatory oversight

Frequently Asked Questions

How long does Humana prior authorization take for Cerezyme? Standard decisions come within 30 days, but complete electronic submissions often receive decisions within one business day. Expedited requests are decided within 72 hours when medical urgency is documented.

What if Cerezyme is non-formulary on my Humana plan? Cerezyme is classified as nonpreferred, with Elelyso as the preferred enzyme replacement therapy. You can request a formulary exception by documenting why the preferred option isn't medically appropriate.

Can I request an expedited appeal in Washington? Yes, if waiting for a standard decision could seriously harm your health. Your doctor must confirm that delay may jeopardize your life, health, or ability to regain maximum function.

Does step therapy apply to Cerezyme? Humana may require trying their preferred enzyme replacement therapy (Elelyso) first. However, if you have medical reasons why the preferred therapy isn't suitable, you can request an exception.

What counts as medical necessity for Cerezyme? Confirmed Type 1 Gaucher disease diagnosis with clinical evidence of disease severity, appropriate dosing within FDA guidelines, and documentation that treatment is expected to provide clinical benefit.

How do I check my appeal status? Use Humana's member portal online or call the customer service number on your member ID card. Keep your appeal confirmation number for tracking.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful approvals for patients needing specialty medications like Cerezyme. Our platform analyzes denial letters, identifies the specific denial basis, and creates targeted, evidence-backed appeals that address payer requirements point-by-point. For patients facing complex prior authorization requirements or appeals, Counterforce Health provides the clinical documentation and regulatory expertise needed to navigate insurance barriers effectively.

Whether you're dealing with step therapy requirements, formulary restrictions, or medical necessity determinations, having the right documentation and appeal strategy can make the difference between denial and approval. Counterforce Health helps ensure your case is presented with the clinical evidence and regulatory compliance that payers expect to see.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan, medical history, and clinical circumstances. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for coverage determinations. For help with appeals in Washington state, contact SHIBA at 1-800-562-6900.

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