By Counterforce Health Team in Elaprase (idursulfase) —

How to Get Elaprase (Idursulfase) Covered by Humana in New York: Complete Appeals Guide

Answer Box: Get Elaprase Covered by Humana in New York

Elaprase (idursulfase) requires prior authorization from Humana Medicare plans. Your fastest path to approval: (1) Have your doctor submit enzymatic/genetic test results confirming Hunter syndrome via Humana's provider portal or fax to 877-486-2621, (2) Include weight-based dosing calculations and infusion monitoring plan, (3) If denied, file internal appeal within 65 days using Humana's appeal form. New York residents cannot use state external appeals for Medicare plans—follow Medicare's federal appeals process instead.

Table of Contents

Start Here: Verify Your Plan and Coverage Requirements

Before requesting Elaprase (idursulfase) coverage, confirm your specific Humana plan type. Most Humana Medicare Advantage and Part D plans require prior authorization for this specialty enzyme replacement therapy used to treat Hunter syndrome (MPS II).

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Must get approval before dispensing Humana Prior Authorization List
Enzymatic Testing Reduced iduronate 2-sulfatase activity Lab results from certified facility
Genetic Confirmation IDS gene sequencing showing pathogenic variant Molecular genetics report
Weight-Based Dosing 0.5 mg/kg weekly IV infusion Provider must calculate and justify dose
Infusion Monitoring Plan for managing infusion reactions Required safety protocols

First step today: Call the member services number on your Humana ID card to verify your specific plan's requirements and formulary status for Elaprase.

Forms You'll Need for Prior Authorization

Primary Form

Medicare Prescription Drug Coverage Determination Form - This is Humana's standard prior authorization request form for Part D medications.

Where to get it: Download from Humana's provider portal or request by calling 800-555-CLIN (2546).

Required Documentation Checklist

✓ Diagnosis confirmation: Hunter syndrome (MPS II) with ICD-10 code
✓ Enzymatic testing: Iduronate 2-sulfatase activity results showing deficiency
✓ Genetic testing: IDS gene sequencing report with pathogenic variant
✓ Weight-based dosing: Patient weight and calculated 0.5 mg/kg weekly dose
✓ Infusion plan: Site of care and monitoring protocols
✓ Prior treatments: Documentation of any previous therapies (if applicable)

Appeal Forms (if needed later)

  • Humana Medicare Appeal Form for coverage determination appeals
  • Appointment of Authorized Representative Form if designating someone to appeal on your behalf

Both forms are available through your MyHumana member portal.

Submission Portals and Methods

Electronic Submission (Fastest)

Provider Portal: Humana providers can submit prior authorization requests through CoverMyMeds or directly via Humana's electronic system.

Member Portal: Patients can track status and submit additional documentation through their MyHumana account.

Fax Submission

Prior Authorization Fax: 877-486-2621

  • Include completed form and all supporting documentation
  • Use a cover sheet with patient name, member ID, and "Elaprase Prior Authorization Request"
  • Request fax confirmation receipt

Phone Support

Clinical Review Line: 800-555-CLIN (2546)

  • Monday–Friday, 8 a.m.–8 p.m. local time
  • Use for urgent cases or submission questions
  • Have member ID and provider NPI ready
Tip: Electronic submissions typically process faster than fax. If your provider doesn't have electronic access, ask them to set up a CoverMyMeds account.

Specialty Pharmacy Coordination

Elaprase is typically dispensed through Humana's specialty pharmacy network, primarily CenterWell Specialty Pharmacy (owned by Humana).

Getting Started with CenterWell

  1. Provider referral: Your doctor sends the prescription to CenterWell via fax (877-405-7940) or e-prescribing
  2. Patient enrollment: Call 800-486-2668 or register online at centerwellpharmacy.com
  3. Home infusion setup: CenterWell coordinates with licensed nurses for at-home administration
  4. Financial assistance: They help identify copay assistance programs and patient support

What CenterWell Handles

  • Prior authorization coordination with your provider
  • Insurance benefit verification
  • Delivery scheduling and cold-chain management
  • Nursing coordination for home infusions
  • Ongoing clinical monitoring and side effect management

For New York residents: CenterWell serves all areas of New York state for home infusion services. If you prefer in-office infusions, verify with your provider that their facility is in Humana's network.

Support Lines and Key Contacts

Member Services

  • Primary number: Use the number on your Humana member ID card
  • General inquiries: 866-427-7478
  • TTY: 800-457-4708 (711)
  • Hours: Monday–Friday, 8 a.m.–8 p.m. local time

Provider Relations

  • Medicare plans: 800-457-4708
  • Commercial plans: 800-448-6262
  • Prior authorization support: 800-555-CLIN (2546)

Case Management for Complex Cases

Specialty Case Management: 866-421-5663

  • Use for transplant cases or complex medical management
  • TTY users call 711
  • Can help coordinate care between multiple specialists
What to ask when calling: Request your call reference number, ask for written confirmation of any verbal approvals, and confirm next steps and timelines.

Appeals Process for Humana Denials

If your initial prior authorization is denied, you have several appeal levels available. Important: New York residents with Humana Medicare plans must use Medicare's federal appeals process, not New York's state external appeal system.

Internal Appeal Timeline

Level Deadline to File Decision Timeline
Initial Appeal 65 days from denial 30 days (pre-service), 60 days (post-service)
Part D Drug Appeal 65 days from denial 7 days standard, 72 hours expedited

Step-by-Step Appeal Process

  1. File internal appeal using Humana's Medicare Appeal Form
  2. Include new evidence such as additional clinical documentation or peer-reviewed studies
  3. Request expedited review if medically urgent (decision within 72 hours)
  4. If denied again, proceed to Medicare's federal appeals process:
    • Level 1: Redetermination by Medicare Administrative Contractor
    • Level 2: Reconsideration by Qualified Independent Contractor
    • Level 3: Administrative Law Judge hearing

Required Information for Appeals

  • Original denial letter with specific reasons
  • Member ID and provider information
  • Additional clinical evidence supporting medical necessity
  • Completed appeal form with signatures

Submit appeals via:

  • Online: MyHumana member portal
  • Fax: Use number provided in denial letter
  • Mail: Address specified in denial notice

New York State Resources and Assistance

While Medicare appeals don't go through New York's external appeal system, New York residents have other support resources available.

Consumer Assistance

Community Health Advocates (CHA)

New York State Department of Financial Services

  • Phone: 800-400-8882
  • Use for: Non-Medicare insurance complaints and general guidance
  • Website: dfs.ny.gov

When to Contact State Resources

  • Questions about your rights under New York insurance law
  • Complaints about insurer behavior or processing delays
  • General guidance on navigating appeals (they'll direct Medicare patients to federal process)
  • Help understanding denial letters or coverage policies

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Documents Needed
Missing enzymatic confirmation Submit lab results showing I2S deficiency Certified lab report with reference ranges
Lack of genetic testing Provide molecular genetics report IDS gene sequencing with pathogenic variant
Insufficient monitoring plan Detail infusion safety protocols Provider letter outlining reaction management
Weight-based dosing unclear Calculate and justify 0.5 mg/kg dose Current weight, dosing calculation, rationale
"Not medically necessary" Cite FDA approval and guidelines FDA label, MPS Society guidelines, peer review

Medical Necessity Letter Checklist for Providers

When writing appeals or initial authorization requests, include:

✓ Hunter syndrome diagnosis with supporting test results
✓ Clinical symptoms and disease progression
✓ FDA approval for idursulfase in MPS II
✓ Weight-based dosing rationale (0.5 mg/kg weekly)
✓ Infusion monitoring plan and safety protocols
✓ Expected outcomes and treatment goals
✓ References: FDA prescribing information, MPS Society treatment guidelines

FAQ: Elaprase Coverage with Humana

How long does Humana prior authorization take for Elaprase? Standard prior authorization decisions are made within 30 days for pre-service requests. Expedited reviews (for urgent medical needs) are completed within 72 hours.

What if Elaprase is non-formulary on my plan? You can request a formulary exception through the same prior authorization process. Include documentation showing medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal in New York? Yes, if you have an urgent medical condition. Humana must respond to expedited appeals within 72 hours. Include a provider letter explaining the urgency.

Does step therapy apply to Elaprase? Step therapy typically doesn't apply since there are no FDA-approved alternatives for Hunter syndrome enzyme replacement therapy. However, verify with your specific plan.

What if I'm traveling outside New York? CenterWell Specialty Pharmacy can coordinate infusions in other states. Contact them at 800-486-2668 to arrange temporary location services.

How much does Elaprase cost without insurance? The wholesale acquisition cost is approximately $3,230 per 6 mg vial (as of June 2025). Monthly costs can exceed $13,000 depending on patient weight and dosing.

Are there financial assistance programs available? Yes, Takeda (the manufacturer) offers patient support programs. CenterWell Specialty Pharmacy can help you apply for manufacturer assistance and copay support programs.

What happens if Humana changes my plan's formulary? If Elaprase is removed from your plan's formulary, you may be eligible for a transition fill while you work on prior authorization or plan changes during open enrollment.

Counterforce Health helps patients and providers navigate complex insurance approvals for specialty medications like Elaprase. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that align with each payer's specific requirements. We understand the unique challenges of getting rare disease treatments approved and work to turn denials into approvals through comprehensive documentation and strategic appeals.

For additional support navigating Humana's approval process, Counterforce Health can help create compelling prior authorization requests and appeals based on your plan's specific criteria.

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 may change. Always verify current requirements with your insurer and consult healthcare providers for medical decisions. For official appeals guidance, contact Humana member services or Medicare directly.

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