By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Covered by Humana in Florida: Complete Prior Authorization Guide with Appeals Process

Answer Box: Getting Chenodal Covered by Humana in Florida

Humana requires prior authorization for Chenodal (chenodiol) in Florida for FDA-approved uses like radiolucent gallstones or cerebrotendinous xanthomatosis (CTX). Submit the Request for Medicare Prescription Drug Coverage Determination form with imaging confirming radiolucent stones, documented ursodiol failure (≥6 months), and surgical risk factors. Fax to 877-486-2621 or use the provider portal for 2-5 day decisions. If denied, appeal within 65 days using Florida's Medicare Advantage process.

First step today: Verify your plan's formulary status using Humana's Drug List Search and gather imaging reports showing radiolucent gallstones.

Table of Contents

  1. Before You Start: Verify Coverage
  2. Gather Required Documentation
  3. Submit Your Prior Authorization Request
  4. Follow-Up and Timeline Expectations
  5. Common Denial Reasons and Fixes
  6. Appeals Process for Florida Humana Members
  7. Renewal and Re-Authorization
  8. Quick Reference Checklist
  9. FAQ

Before You Start: Verify Coverage

Check Your Plan Type and Formulary Status

First, confirm whether you have Humana Medicare Advantage, Medicare Part D, or commercial coverage. Chenodal's coverage varies by plan type:

  • Medicare Advantage/Part D: Most likely covered with prior authorization
  • Commercial plans: Coverage varies; check your specific formulary

Use Humana's Prior Authorization Search Tool to verify if Chenodal requires PA for your specific plan. The drug appears in Humana's pharmacy policies with coverage effective through August 20, 2025.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for most plans Humana PA Search
Formulary Tier Plan-specific (typically specialty tier) Drug List Search
Age Requirement ≥18 years FDA labeling
Primary Indication Radiolucent gallstones, surgical non-candidate Humana pharmacy policies
Step Therapy Ursodiol failure required (≥6 months) Payer-specific criteria
Dosing Limit ≤18 mg/kg/day FDA maximum

Gather Required Documentation

Medical Records You'll Need

Essential Documentation:

  • Recent imaging (ultrasound, CT, or oral cholecystogram) confirming radiolucent stones and well-opacifying gallbladder
  • Documented ursodiol trial records showing dose, duration (≥6 months), and reason for failure/intolerance
  • Surgical consultation notes explaining increased operative risk
  • Baseline liver function tests (LFTs)
  • Current prescription with dosing rationale

Clinician Corner: Medical Necessity Letter

Your prescriber's letter should include:

  1. Patient demographics and diagnosis with appropriate ICD-10 codes (K80.20 for calculus of gallbladder without obstruction)
  2. Clinical presentation describing symptomatic gallstones impacting quality of life
  3. Prior therapy documentation: Specific ursodiol dosing (8-10 mg/kg/day), duration, and clinical response
  4. Surgical contraindications: Age >70, comorbidities, anesthesia risks, patient preference with medical justification
  5. Proposed treatment plan: Chenodiol dosing (13-16 mg/kg/day), monitoring schedule, treatment duration
  6. Supporting evidence: Reference FDA labeling and clinical dissolution rates (13-38% success)
Tip: Include specific dates and dosages for all prior therapies. Vague statements like "failed conservative management" often lead to denials.

Submit Your Prior Authorization Request

Step-by-Step: Fastest Path to Approval

  1. Download the correct form: Use Humana's Request for Medicare Prescription Drug Coverage Determination (verify current link on Humana's site)
  2. Complete all sections: Patient information, prescriber details, drug name (Chenodal/chenodiol), strength, quantity, and medical justification
  3. Attach supporting documents: Medical necessity letter, imaging reports, ursodiol records, surgical consultation, baseline labs
  4. Submit via preferred method:
    • Provider portal (fastest: 2-5 days)
    • CoverMyMeds platform
    • Fax: 877-486-2621
    • Phone: 1-800-523-0023 (clinical intake)
  5. Request confirmation: Get reference number and expected decision date
  6. Track status: Use provider portal or call member services
  7. Follow up: Call if no decision within stated timeframe

Submission Tips

  • Submit complete packets to avoid delays from requests for additional information
  • For urgent cases, request expedited review (72-hour decision)
  • Include pharmacy information if using specialty pharmacy routing

Counterforce Health helps patients and providers streamline this process by analyzing denial letters and generating targeted appeals with the right evidence and documentation to meet payer-specific requirements.

Follow-Up and Timeline Expectations

Standard Timelines for Humana in Florida

Decision Type Standard Timeline Expedited Timeline
Pre-service 30 days 72 hours
Payment 60 days 72 hours
Part D drugs 7 days 72 hours

When to Call Humana

  • Day 1: Confirm receipt and get reference number
  • Day 7: Check status if no initial response
  • Day 14: Escalate if approaching deadline
  • Day 30: File complaint if decision overdue

Sample Call Script: "I'm calling to check the status of prior authorization request #[reference number] for Chenodal submitted on [date]. Can you provide an update on the review timeline and any additional information needed?"

Common Denial Reasons and Fixes

Denial Reason How to Fix Required Documentation
Missing radiolucent stone confirmation Submit detailed imaging reports Ultrasound/CT with radiologist interpretation
Inadequate ursodiol trial Provide complete pharmacy records Prescription history with dates, doses, duration
Surgical candidate Document specific contraindications Surgical consultation, comorbidity assessments
Non-opacifying gallbladder Submit contrast studies HIDA scan or oral cholecystogram
Off-label use without support For CTX: cite standard-of-care literature Genetic testing, specialist consultation

From Our Advocates

"We've seen the most success when providers submit imaging reports that explicitly state 'radiolucent stones' rather than just 'gallstones.' The terminology matters significantly to utilization management reviewers who are looking for specific language that matches policy criteria."

Appeals Process for Florida Humana Members

Level 1: Internal Appeal (Plan Review)

Timeline: 65 days from denial notice to file Decision: 30 days (standard), 72 hours (expedited) How to file:

  • Call 1-800-833-6917
  • Submit via member portal
  • Mail to address on denial notice

Required documents:

  • Original denial letter
  • New medical evidence
  • Updated physician letter addressing denial reasons
  • CMS Model Appeal Form (verify current link)

Level 2: Independent Review Entity (IRE)

Automatic advancement if Level 1 denied Timeline: 65 days from plan decision Decision: Matches Level 1 timelines Process: Handled through CMS appeals portal

Higher Appeal Levels

  • Level 3: Administrative Law Judge (ALJ) - $190+ threshold (2025)
  • Level 4: Medicare Appeals Council
  • Level 5: Federal Court - $1,900+ threshold (2025)
Note: Florida's Department of Financial Services (1-877-693-5236) handles state-regulated insurance but defers Medicare Advantage appeals to federal CMS processes.

Renewal and Re-Authorization

When to Resubmit

Chenodal typically requires reauthorization every 12 months with a lifetime maximum of 24 months for gallstone dissolution.

Renewal Documentation

  • Follow-up imaging at 12-18 months showing treatment response
  • Updated liver function tests confirming safety
  • Clinical progress notes documenting symptom improvement
  • Continued medical necessity if stones persist

Calendar renewal requests 30-45 days before current authorization expires to prevent therapy interruption.

Quick Reference Checklist

Before Starting:

  • Verify PA requirement for your specific Humana plan
  • Confirm in-network provider status
  • Check if specialty pharmacy required

Required Documents:

  • Imaging confirming radiolucent stones and opacifying gallbladder
  • Ursodiol trial documentation (≥6 months)
  • Surgical consultation explaining contraindications
  • Baseline liver function tests
  • Medical necessity letter with specific clinical details

Submission:

  • Complete Humana PA form
  • Submit via provider portal (fastest) or fax 877-486-2621
  • Request confirmation and reference number
  • Track status weekly

If Denied:

  • Review denial reason carefully
  • Gather additional evidence addressing specific concerns
  • File appeal within 65 days
  • Request expedited review if urgent

FAQ

How long does Humana prior authorization take in Florida? Standard decisions take up to 30 days for pre-service requests, 7 days for Part D drugs. Expedited reviews are completed within 72 hours when medical urgency is documented.

What if Chenodal is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate. Submit the same documentation as a standard PA with additional justification for why covered alternatives won't work.

Can I request an expedited appeal if denied? Yes, if your health could be seriously jeopardized by waiting for a standard appeal timeline. Your doctor must certify the urgent medical need in writing.

Does step therapy apply if I failed ursodiol outside Florida? Yes, documented ursodiol failure from any location counts toward step therapy requirements. Ensure you have complete pharmacy records and clinical notes from the treating physician.

What happens if I start Chenodal before PA approval? You'll be responsible for the full cost until authorization is approved. Humana may provide retroactive coverage if the PA is ultimately approved, but this isn't guaranteed.

How much does Chenodal cost without insurance? Brand-name pricing varies by strength and pharmacy. Check with your pharmacy for current cash prices or explore manufacturer assistance programs through Travere Therapeutics (verify current patient support options).

Who can I contact for help with appeals in Florida? Florida SHINE (1-800-963-5337) provides free Medicare counseling and appeals assistance. For complex cases, consider consulting with healthcare advocates or attorneys specializing in insurance appeals.

Getting Chenodal covered by Humana in Florida requires careful attention to documentation and timing, but success rates improve significantly when submissions include complete clinical evidence addressing payer-specific criteria. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and generating evidence-backed responses that speak directly to utilization management requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with Humana and consult healthcare professionals for medical decisions. For specific legal guidance on insurance appeals, consult an attorney specializing in healthcare law.

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