By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Covered by Humana in New York: Complete Prior Authorization Guide

Answer Box: Getting Chenodal (Chenodiol) Covered by Humana in New York

Chenodal (chenodiol) requires prior authorization from Humana for radiolucent gallstones in surgical non-candidates. The fastest path to approval: 1) Gather imaging confirming radiolucent stones and well-opacifying gallbladder, 2) Document 6-month ursodiol trial failure or contraindication, 3) Submit PA via Humana provider portal or fax 877-486-2621. If denied, New Yorkers can appeal through New York State Department of Financial Services external review within 4 months. Start today by calling Humana at the number on your insurance card to confirm formulary status.

Table of Contents

Humana Plan Types & Coverage Implications

Humana operates primarily through Medicare Advantage and Part D plans in New York, with some commercial employer coverage. Your plan type affects your appeal rights and timelines:

  • Medicare Advantage (Part C): 65 days to appeal denials; standard decisions within 14 days, expedited within 72 hours
  • Medicare Part D: 65 days to appeal; standard coverage determinations within 72 hours, expedited within 24 hours
  • Commercial plans: Follow New York state appeal timelines (internal appeals, then external review through DFS)
Note: Over 95% of New Yorkers have health insurance, with strong state protections for appeals regardless of plan type.

Formulary Status & Tier Placement

Chenodal (chenodiol) tier placement varies by specific Humana plan. Based on available data, specialty drugs like Chenodal typically fall on:

  • Tier 3 (Non-preferred brand): Higher copay/coinsurance
  • Tier 4 (Specialty): Highest cost-sharing, 30-day supply limits

Coverage at a Glance

Requirement Details Where to Verify Source
Prior Authorization Required for all uses Humana formulary lookup Drug List Search
Step Therapy 6-month ursodiol trial PA policy Provider Resources
Quantity Limits 30-day supply maximum Plan documents Plan-specific formulary
Site of Care Specialty pharmacy preferred CenterWell network Specialty Pharmacy

Prior Authorization Requirements

All Chenodal prescriptions require prior authorization regardless of indication. Humana follows FDA-approved criteria plus additional step therapy requirements.

Medical Necessity Criteria

All conditions must be met:

  • Radiolucent (cholesterol) gallstones confirmed by imaging within 6 months
  • Well-opacifying gallbladder on oral cholecystography or HIDA scan
  • Patient is not a surgical candidate due to age (>70) or systemic disease
  • No gallstone complications (cholecystitis, obstruction, pancreatitis)
  • Normal liver function tests
  • Documented ursodiol trial failure (6+ months at 8-10 mg/kg/day) OR contraindication

Required Documentation Checklist

Before submitting PA, gather:

  • Recent imaging reports (ultrasound, CT, or KUB) showing radiolucent stones
  • Gallbladder function study (oral cholecystography or HIDA scan)
  • Ursodiol trial records with specific dates, dosing, and failure documentation
  • Surgical consultation or anesthesia risk assessment
  • Baseline liver function tests (within 3 months)
  • ICD-10 code K80.20 (calculus of gallbladder without obstruction)

Specialty Pharmacy Network

Chenodal must be dispensed through Humana's preferred specialty pharmacy network, primarily CenterWell Specialty Pharmacy.

Enrollment Process

  1. Prescriber: E-prescribe or fax prescription to CenterWell at 1-877-405-7940
  2. Patient: Complete enrollment via phone interview
  3. Pharmacy: Coordinates PA submission and insurance verification
  4. Delivery: 30-day supplies shipped to patient's home
Tip: CenterWell handles most PA paperwork directly with prescribers, streamlining the process.

Cost-Share Dynamics

Chenodal costs vary significantly based on tier placement and plan type. Educational estimates for planning:

  • Tier 3: 25-50% coinsurance after deductible
  • Tier 4 (Specialty): 25-33% coinsurance, often $100-500+ monthly
  • Medicare Part D: Coverage gap ("donut hole") may apply until catastrophic threshold

Potential Savings Options

  • Manufacturer support: Check Travere Therapeutics patient resources for copay assistance programs
  • State programs: New York residents may qualify for Extra Help (Medicare Part D) or state pharmaceutical assistance

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Verify coverage (Patient/Clinic): Call Humana member services to confirm current formulary status
  2. Gather documentation (Clinic): Collect all required clinical records and imaging
  3. Complete PA form (Prescriber): Submit "Request for Medicare Prescription Drug Coverage Determination" via provider portal
  4. Submit supporting docs (Clinic): Attach medical necessity letter, imaging, and ursodiol trial records
  5. Track submission (Patient): Get reference number and follow up at 72 hours
  6. Receive decision (All): Standard timeline is 72 hours for Part D, 14 days for Medicare Advantage
  7. Appeal if denied (Patient): File internal appeal within 65 days

Submission Methods

  • Fastest: Provider portal (2-5 day decisions)
  • Alternative: Fax to 877-486-2621
  • Phone: 800-555-2546 for urgent cases

Appeals Process for New York

New York residents have strong appeal rights through both Humana's internal process and state external review.

Internal Appeals Timeline

  • First appeal: 65 days to file, 30 days for decision (Medicare Advantage)
  • Second appeal: 65 days to file, 30 days for decision
  • Expedited: 72 hours for urgent medical needs

Required Appeal Documents

  • Original denial letter
  • Medical necessity letter addressing specific denial reasons
  • Additional clinical evidence (peer-reviewed studies, guidelines)
  • Patient impact statement

New York External Review Rights

After exhausting Humana's internal appeals, New York residents can request external review through the Department of Financial Services.

External Review Process

  • Timeline: 4 months from final internal denial to file
  • Cost: Maximum $25 fee (waived for financial hardship/Medicaid)
  • Decision time: 30 days standard, 72 hours expedited
  • Binding: External reviewer decision is final and enforceable

When to Use External Review

  • Denial based on "experimental/investigational" determination
  • Medical necessity disputes with strong clinical evidence
  • Off-label use with compendia support
From our advocates: "We've seen New York external reviews overturn Humana denials when providers submit comprehensive literature reviews showing established clinical benefits. The key is addressing the specific denial reason with peer-reviewed evidence, not just repeating the original request."

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Ursodiol not tried first" Document trial failure Pharmacy records, provider notes with dates/dosing
"Not medically necessary" Strengthen clinical justification Surgical consultation, comorbidity documentation
"Experimental for off-label use" Provide compendia support AHFS, Micromedex, or specialty guidelines
"Imaging insufficient" Submit complete radiology reports Recent ultrasound/CT with radiologist interpretation

Clinician Documentation Requirements

Medical Necessity Letter Checklist

Essential elements for approval:

  • Problem statement: Patient's gallstone symptoms and impact on quality of life
  • Prior treatments: Specific ursodiol trial details (dates, dosing, response, discontinuation reason)
  • Clinical rationale: Why surgery is contraindicated (age, comorbidities, anesthesia risk)
  • Treatment plan: Proposed chenodiol dosing (13-16 mg/kg/day), monitoring schedule
  • Literature support: FDA labeling reference, relevant clinical studies

Key Clinical References

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and payer policies to identify specific coverage criteria, then drafts point-by-point rebuttals with the right clinical evidence and procedural requirements. For complex cases like Chenodal appeals, Counterforce Health streamlines the documentation process and tracks payer-specific deadlines.

FAQ

How long does Humana prior authorization take for Chenodal? Standard timeline is 72 hours for Medicare Part D, up to 14 days for Medicare Advantage. Expedited reviews available for urgent medical needs.

What if Chenodal is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. New York residents can appeal denials through state external review.

Can I get expedited approval if I'm currently hospitalized? Yes, request expedited review citing serious health risk. Humana must respond within 24-72 hours depending on plan type.

Does step therapy apply if I failed ursodiol outside New York? Yes, document the trial failure with pharmacy records and provider notes. Out-of-state records are acceptable with proper documentation.

What's the maximum treatment duration Humana covers? Typically 12 months initially, with one 12-month renewal possible. Total treatment should not exceed 24 months per FDA guidelines.

How do I find a New York attorney for insurance appeals? Contact Community Health Advocates at 888-614-5400 for free assistance with insurance denials and appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals in New York, contact the Department of Financial Services or Community Health Advocates.

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