By Counterforce Health Team in Dupixent (dupilumab) —

How to Get Dupixent (dupilumab) Covered by Humana in Georgia: Complete Guide to Forms, Appeals, and Approval

Answer Box: Getting Dupixent Covered by Humana in Georgia

Dupixent (dupilumab) requires prior authorization from Humana with documented step therapy failures. Your prescriber submits the PA request through Humana's provider portal with medical necessity documentation. If denied, you have 65 days to appeal internally, then can request Georgia's free external review within 60 days of the final denial. Start today: Contact your prescriber to initiate the prior authorization process and gather documentation of failed topical treatments (atopic dermatitis) or inhaled therapies (asthma).

Table of Contents

Coverage Basics

Is Dupixent Covered by Humana?

Yes, Dupixent is covered by most Humana plans but requires prior authorization and is typically placed on Tier 4 (specialty tier), resulting in 25-33% coinsurance after your deductible. Coverage applies to FDA-approved indications including atopic dermatitis (≥6 months), asthma add-on therapy (≥6 years), chronic rhinosinusitis with nasal polyps, prurigo nodularis, and eosinophilic esophagitis.

Which Humana Plans Cover Dupixent?

  • Medicare Advantage (Part C): Prior authorization required for medical benefit coverage
  • Medicare Part D: For self-administered injections
  • Commercial plans: Subject to employer-specific formulary placement
  • Medicaid managed care: Where Humana operates in Georgia
Note: Self-funded employer plans may have different requirements than standard Humana policies.

Prior Authorization Process

Who Submits the Request?

Your prescriber (dermatologist, allergist, pulmonologist, or primary care physician) must submit the prior authorization request. Patients cannot submit PA requests directly to Humana.

Required Documentation

Your prescriber must include:

  • Confirmed diagnosis with appropriate ICD-10 codes (L20.9 for atopic dermatitis, J45.9 for asthma)
  • Disease severity assessment using standardized scoring (EASI or IGA scores for dermatitis, ACT scores for asthma)
  • Complete prior treatment history with specific medications, doses, durations, and clinical outcomes
  • Clinical rationale for Dupixent over alternatives
  • Age-appropriate prescribing per FDA labeling
  • Laboratory results if applicable (CBC, eosinophil count, IgE levels)

Submission Methods

Prescribers can submit via:

  • Humana provider portal (preferred method)
  • Fax: 1-888-447-3430 for professionally administered drugs
  • Electronic prior authorization through integrated systems

Timing and Deadlines

Process Timeline Notes
Standard PA Decision 7 calendar days From complete submission
Expedited PA 72 hours For urgent medical situations
Internal Appeal Filing 65 days From denial notice date
Internal Appeal Decision 30 days (Part C), 7 days (Part D) Standard timelines
External Review Filing 60 days From final internal denial
External Review Decision 30 business days Georgia DOI process

Source: Humana Appeals Process

Step Therapy Requirements

Humana requires documented failure of first-line therapies before approving Dupixent:

Atopic Dermatitis

  • Trial of topical corticosteroids or calcineurin inhibitors
  • Document specific agents, durations, and measurable outcomes
  • Cannot be just "inadequate response" - must show specific clinical results

Asthma

  • Trial of inhaled corticosteroids plus long-acting beta-agonists
  • May require trial of other biologics (Xolair, Nucala, or Tezspire)
  • Document lung function tests and symptom control measures

Chronic Rhinosinusitis with Nasal Polyps

  • Trial of intranasal corticosteroids
  • Documentation of inadequate surgical or medical management
  • CT imaging showing polyp burden may be required

Source: Humana Prior Authorization Requirements

Cost and Coverage Details

Out-of-Pocket Costs

  • List price: Approximately $3,993 per carton (2 injections) as of January 2025
  • Typical patient cost: 79% of Medicare Part D patients pay $0-$100 per month
  • Medicare Part D out-of-pocket maximum: $2,100 annually for 2026
  • Coinsurance: 25-33% after deductible for Tier 4 medications

Cost Assistance Options

Manufacturer Support: Dupixent offers a copay assistance program that may reduce out-of-pocket costs for eligible patients. Visit dupixent.com/support-savings for current eligibility requirements.

Foundation Programs: Patient assistance foundations may provide grants for eligible patients with financial need.

Appeals Process in Georgia

Internal Appeals with Humana

Step 1: Peer-to-Peer Review Before filing a formal appeal, your prescriber can request a peer-to-peer discussion with Humana's medical director using the contact number on your denial notice.

Step 2: Formal Internal Appeal

  • Deadline: 65 days from denial notice
  • Submit via: Humana appeals portal, mail, or fax
  • Required documents: Denial notice, medical records, prescriber letter
  • Decision timeline: 30 days for Part C, 7 days for Part D

Georgia External Review Process

If Humana's internal appeal is denied, Georgia law provides a free external review conducted by independent medical experts.

Eligibility:

  • Must exhaust Humana's internal appeals first
  • Applies to medical necessity determinations
  • Available for fully insured plans (not self-funded ERISA plans)

Filing Process:

  1. Deadline: 60 days from Humana's final denial letter
  2. Submit to: Georgia Department of Insurance Consumer Services
  3. Contact: 1-800-656-2298 or online at oci.ga.gov
  4. Required documents: Final denial letter, medical records, prescriber statement

Timeline: 30 business days for standard review, 72 hours for expedited urgent cases

Decision: Binding on Humana - they must cover the service if approved

Source: Georgia External Review Process

From our advocates: We've seen Dupixent appeals succeed when prescribers include specific EASI scores showing disease severity and document exact topical therapies tried with dates and clinical response. One case involved a patient whose appeal was initially denied but approved on external review when the dermatologist provided photos showing treatment progression and detailed dosing history of failed conventional therapies.

Common Denial Reasons

Denial Reason How to Address
Insufficient diagnosis documentation Include ICD-10 codes, disease severity scores, specialist consultation notes
Missing step therapy documentation Provide detailed trial history with specific medications, doses, durations, and outcomes
Age restrictions Verify FDA-approved age ranges and document appropriately
Quantity limits exceeded Justify dosing based on FDA labeling and clinical guidelines
"Not medically necessary" Submit comprehensive medical necessity letter with clinical evidence

Specialty Pharmacy Requirements

Dupixent requires dispensing through Humana's specialty pharmacy network as a Tier 4 medication. Your prescription will automatically be transferred to an approved specialty pharmacy, which will:

  • Coordinate with your prescriber for refill authorizations
  • Provide injection training and support
  • Handle prior authorization renewals
  • Offer patient assistance program coordination

Frequently Asked Questions

Q: How long does Humana's prior authorization take in Georgia? A: Standard decisions are made within 7 calendar days. Expedited reviews for urgent situations are completed within 72 hours.

Q: What if Dupixent is non-formulary on my plan? A: You can request a formulary exception through the same prior authorization process, providing medical necessity documentation.

Q: Can I request an expedited appeal? A: Yes, if waiting for standard processing would seriously jeopardize your health or ability to function. Your physician must justify the urgency.

Q: Does step therapy apply if I failed treatments in another state? A: Yes, documented treatment failures from other states satisfy step therapy requirements if properly documented in your prior authorization request.

Q: What happens if I miss the appeal deadline? A: You may request an extension by showing "good cause" such as serious illness. Contact Humana immediately to discuss options.

Q: How often do I need to renew prior authorization? A: Typically annually, but Humana may require more frequent reviews based on your specific plan and clinical status.

When to Escalate

Contact Georgia Department of Insurance

If you encounter problems with Humana's appeals process or believe your rights have been violated:

Georgia DOI Consumer Services

Additional Georgia Resources

Georgians for a Healthy Future: Nonprofit providing consumer assistance with insurance appeals and coverage issues.

Georgia Legal Services Program: Free legal assistance for eligible low-income residents facing insurance denials.

Getting Help with Your Appeal

Navigating insurance approvals for specialty medications like Dupixent can be complex and time-consuming. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies specific denial reasons, and drafts point-by-point rebuttals aligned with each payer's own policies and requirements.

For Dupixent appeals specifically, Counterforce Health pulls relevant citations from FDA labeling, peer-reviewed studies, and specialty guidelines while ensuring all required clinical documentation is included. The system produces appeals that meet Humana's procedural requirements while tracking deadlines and required supporting documents. This approach helps reduce the back-and-forth often seen with specialty medication approvals and can significantly improve approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage requirements and appeal processes may vary by plan and can change. Always consult your healthcare provider for medical decisions and review your specific insurance policy for coverage details. For the most current information about Georgia's external review process, contact the Georgia Department of Insurance directly.

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