How to Get Cresemba (Isavuconazole) Covered by Humana in Georgia: Timeline, Forms & Appeal Process
Answer Box: Getting Cresemba Covered by Humana in Georgia
Cresemba (isavuconazole) requires prior authorization from Humana with decisions typically within 1 business day for electronic submissions (95% by 2026) or 7 calendar days maximum under CMS rules. Key requirements: invasive aspergillosis or mucormycosis diagnosis, ID specialist involvement, and documented failure/contraindication to voriconazole for aspergillosis cases. First step: Have your infectious disease physician submit a complete electronic PA through Humana's provider portal with diagnostic evidence, treatment history, and medical necessity justification. If denied, you have 65 days to appeal and can request external review through Georgia's Department of Insurance within 60 days of final denial.
Table of Contents
- Coverage Requirements at a Glance
- Timeline: Pre-Submission to Decision
- Step-by-Step: Fastest Path to Approval
- Medical Necessity Documentation
- Appeals Process in Georgia
- Common Denial Reasons & Solutions
- Costs & Patient Support Programs
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | Details | Where to Verify |
|---|---|---|
| Prior Authorization | Required for all Cresemba prescriptions | Humana PA Search Tool |
| Age/Weight Limits | IV: ≥1 year; Capsules: ≥6 years and ≥16 kg | FDA Label |
| Covered Diagnoses | Invasive aspergillosis, invasive mucormycosis only | Humana formulary |
| Prescriber Requirement | ID specialist or in collaboration with ID | PA form |
| Step Therapy | May require voriconazole trial/failure for aspergillosis | Plan-specific policy |
| Appeal Deadline | 65 days from denial notice (Part D) | Humana Appeals |
Timeline: Pre-Submission to Decision
Phase 1: Pre-Submission Preparation (0-2 days)
What happens: Gather required documentation and verify coverage requirements
- Review patient's Humana plan formulary status
- Collect diagnostic evidence (cultures, imaging, pathology)
- Obtain ID specialist consultation notes
- Document prior antifungal therapy history
Phase 2: Submission and Initial Review (1 business day to 7 calendar days)
Electronic submissions: Humana commits to 1 business day decisions for 95% of complete electronic PAs by January 2026 Standard timeline: 7 calendar days maximum under CMS Medicare Advantage rules Expedited review: 72 hours when delay may seriously jeopardize health
Phase 3: Additional Information Requests (1-7 days if needed)
If initial submission is incomplete, Humana may request:
- Additional clinical documentation
- Specialist consultation notes
- Laboratory or imaging results
- Prior therapy failure documentation
Phase 4: Decision and Next Steps
If approved: PA authorization typically valid for 6 months, requires specialty pharmacy If denied: 65-day window to file internal appeal, then external review options in Georgia
Step-by-Step: Fastest Path to Approval
1. Verify Coverage and Requirements
Who: Patient or clinic staff Action: Check Humana's drug formulary and PA requirements Timeline: Same day
2. Obtain ID Specialist Consultation
Who: Treating physician Action: Secure infectious disease consultation if not already involved Documentation needed: Diagnosis confirmation, treatment rationale, alternative therapy assessment Timeline: 1-2 days (urgent consults available)
3. Gather Diagnostic Evidence
Who: Clinical team Required documents:
- Fungal culture results or pathology showing invasive mold
- Imaging (CT chest/sinus, MRI) demonstrating invasive disease
- Relevant biomarkers (galactomannan, β-D-glucan)
- ICD-10 codes: B44.x (aspergillosis) or B46.x (mucormycosis)
4. Document Prior Therapy History
Critical for approval: Evidence of voriconazole failure, intolerance, or contraindication for aspergillosis cases Include: Start/stop dates, adverse effects, clinical response, drug interactions
5. Submit Electronic PA
Who: ID specialist or treating physician Method: Humana provider portal (preferred for 1-day turnaround) Mark urgent if delay poses serious health risk
6. Follow Up Proactively
Timeline: Check status after 1 business day for electronic submissions Contact: Humana provider services or member services number on ID card
7. Coordinate with Specialty Pharmacy
Upon approval: Enroll with Humana-designated specialty pharmacy Required: PA authorization number and quantity limits from approval letter
From our advocates: "We've seen the fastest approvals when ID specialists submit complete electronic PAs that directly address step therapy requirements. Including a brief statement about why voriconazole isn't appropriate—whether due to drug interactions, QT prolongation risk, or prior liver toxicity—often prevents the back-and-forth requests that delay approval."
Medical Necessity Documentation
Core Elements for Strong PA Submission
Diagnosis and Severity
- Specific diagnosis: "proven invasive pulmonary aspergillosis" vs. "possible fungal infection"
- Site of infection and extent
- Host risk factors (neutropenia, transplant status, immunosuppression)
Clinical Evidence
- Microbiology: positive cultures, galactomannan levels, β-D-glucan
- Pathology: tissue biopsy showing invasive fungal elements
- Imaging: characteristic findings on CT or MRI
Treatment Rationale
- Why Cresemba is preferred over formulary alternatives
- Specific contraindications to voriconazole (hepatotoxicity, drug interactions, QT prolongation)
- For mucormycosis: why amphotericin B isn't appropriate or as step-down therapy
Monitoring Plan
- Planned duration of therapy
- Clinical and laboratory monitoring schedule
- Goals of treatment and success metrics
Clinician Corner: Medical Necessity Letter Template
A strong letter should include:
- Patient identification and diagnosis with ICD-10 codes
- Clinical presentation and diagnostic workup results
- Prior antifungal therapy with specific dates, doses, and outcomes
- Rationale for Cresemba citing relevant guidelines or literature
- Contraindications to preferred agents with clinical details
- Treatment plan including duration and monitoring
Reference guidelines from the Infectious Diseases Society of America and European guidelines when appropriate.
Appeals Process in Georgia
Internal Appeal with Humana
Timeline: Must file within 65 days of denial notice Decision deadline:
- Standard: 30 days (pre-service) or 60 days (post-service)
- Expedited: 72 hours when delay may jeopardize health
How to file:
- Online: Humana member portal
- Phone: Number on member ID card
- Mail/Fax: Use Humana's appeal forms
External Review in Georgia
If Humana's internal appeal is denied, Georgia residents can request external review through the Georgia Department of Insurance.
Timeline: Must file within 60 days of Humana's final denial letter Process: Independent physicians review your case Cost: Free to consumers Decision: Typically within 30 business days (72 hours for urgent cases)
How to request:
- Contact: Georgia DOI Consumer Services at 1-800-656-2298
- Forms: Available on Georgia DOI website
- Required: Copy of denial letter, medical records, prescriber statement
Note: Georgia's external review decision is binding on Humana and required by state law to be honored.
Common Denial Reasons & Solutions
| Denial Reason | Solution | Required Documentation |
|---|---|---|
| Step therapy not met | Document voriconazole failure/contraindication | Prior therapy records, adverse event notes, drug interaction list |
| Not medically necessary | Strengthen clinical justification | ID consult note, diagnostic evidence, treatment guidelines |
| Diagnosis not confirmed | Provide definitive diagnostic evidence | Culture results, pathology report, imaging with radiologist interpretation |
| Prescriber not qualified | Ensure ID specialist involvement | ID consultation note or co-signature |
| Off-label use | Confirm on-label indication | FDA labeling, appropriate ICD-10 codes |
Costs & Patient Support Programs
Manufacturer Support
CRESEMBA Support Solutions provides:
- Benefits verification and PA assistance
- Form completion and submission tracking
- Specialty pharmacy coordination
- Contact: Astellas Support
Financial Assistance
- Copay cards: Available for commercially insured patients
- Patient assistance programs: For uninsured or underinsured patients
- Foundation grants: Through organizations like HealthWell Foundation
Specialty Pharmacy Requirements
Most Humana plans require Cresemba to be dispensed through designated specialty pharmacies. The PA approval letter will specify:
- Authorized pharmacy network
- Quantity limits and refill parameters
- Any step-down requirements (IV to oral)
Frequently Asked Questions
How long does Humana prior authorization take for Cresemba in Georgia? Electronic submissions: 1 business day for 95% of complete requests by 2026. Standard maximum: 7 calendar days under CMS rules. Expedited: 72 hours for urgent cases.
What if Cresemba is non-formulary on my Humana plan? Request a formulary exception within 72 hours (standard) or 24 hours (expedited). Must demonstrate medical necessity and failure/contraindication to formulary alternatives.
Can I get an expedited appeal if my infection is life-threatening? Yes. Contact Humana immediately and have your ID specialist document that delay would seriously jeopardize your health. Expedited appeals must be decided within 72 hours.
Does step therapy apply if I failed voriconazole outside Georgia? Yes, prior therapy history from any location counts. Provide documentation of the previous trial, including dates, doses, and reason for discontinuation.
What happens if Humana denies my appeal? Georgia residents can request external review through the Georgia Department of Insurance within 60 days. This independent review is free and binding on Humana.
How often do I need to renew Cresemba authorization? Typically every 6 months. Submit renewal requests 30 days before expiration to avoid treatment gaps. Include updated clinical status and ongoing medical necessity.
Can I use GoodRx or other discount programs with Humana? Generally no, if you're using Humana coverage. However, you can compare costs and potentially pay cash with discount programs if it's less than your Humana copay.
What if I need Cresemba while hospitalized? Hospital use may be covered under Part B medical benefits rather than Part D pharmacy benefits. The hospital will handle authorization, but ensure outpatient continuation is approved before discharge.
Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Cresemba. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address each payer's specific requirements. For patients and clinicians dealing with prior authorization challenges, Counterforce Health provides the tools and expertise needed to navigate complex coverage decisions and secure access to essential treatments.
If you're facing a Cresemba denial from Humana in Georgia, remember that you have strong appeal rights under both federal Medicare rules and Georgia state law. The key is acting quickly within the required timeframes and providing comprehensive clinical documentation that directly addresses the plan's medical necessity criteria.
Sources & Further Reading
- Humana Prior Authorization Search Tool
- FDA Cresemba Prescribing Information
- Georgia Department of Insurance Consumer Services
- Humana Appeals and Exceptions
- CRESEMBA Support Solutions
- Medicare Part D Appeals Process
This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance regarding your situation. For additional help with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.
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