By Counterforce Health Team in Elevidys (delandistrogene moxeparvovec-rokl) —

How to Get Elevidys Covered by Humana in Virginia: Complete Prior Authorization Guide with Forms and Appeal Scripts

Answer Box: Getting Elevidys Covered by Humana in Virginia

Elevidys (delandistrogene moxeparvovec-rokl) requires prior authorization from Humana for ambulatory DMD patients aged 4+ with confirmed genetic mutations. First step: Verify your plan type (Medicare Advantage vs. Part D) and contact a certified DMD center in Virginia. Fastest path: Submit PA request with genetic testing, anti-AAV antibody titers <1:400, and ambulatory status documentation. If denied: You have 65 days for Medicare appeals or can file Virginia external review within 120 days using Form 216-A.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Age Eligibility 4+ years old, ambulatory Medical records confirming walking ability FDA Label
DMD Diagnosis Confirmed genetic mutation DMD gene testing results Medical Necessity Criteria
Genetic Exclusion No exon 8/9 deletions Genetic test showing specific mutations Coverage Policies
Anti-AAV Antibodies Titers <1:400 baseline Lab results for anti-AAVrh74 Clinical Requirements
Prior Authorization Required before treatment Complete PA form with clinical docs Humana PA Portal

Before You Start: Plan Verification

Confirm Your Humana Plan Type

Medicare Advantage or Part D patients: Elevidys is typically covered under Part B medical benefit when administered as an infusion at a qualified center. Contact Humana at 1-800-833-6917 to verify your specific plan's coverage.

Key verification questions to ask:

  • Is prior authorization required for Elevidys?
  • What's my plan's formulary tier for this medication?
  • Are there designated centers of excellence requirements?
  • What's my out-of-pocket maximum for specialty medications?
Note: Humana's Medicare Advantage PA denial rate is approximately 3.5% as of 2023, among the lowest of major insurers, but denials often stem from incomplete documentation.

Check In-Network Status

Verify that your chosen DMD center is in-network with your Humana plan. Out-of-network administration could result in significantly higher costs or denial of coverage.

What You Need to Gather

Essential Documentation Checklist

Medical Records:

  • DMD genetic testing results (must show disease-causing mutation)
  • Anti-AAVrh74 antibody titer lab results
  • Current ambulatory status assessment
  • Weight and dosing calculations
  • Liver function tests and cardiac monitoring baseline

Insurance Documentation:

  • Humana member ID card
  • Prior authorization form (obtain from Humana provider portal)
  • Previous therapy documentation if applicable

Clinical Notes:

  • Neuromuscular specialist evaluation
  • Treatment history and rationale
  • Contraindication screening results
Tip: Request all documentation at least 2-3 weeks before your planned treatment date to allow for processing time.

Step-by-Step Prior Authorization Process

Step 1: Provider Initiates PA Request

Who: Your DMD specialist or center Timeline: Submit 2-3 weeks before planned treatment Method: Humana provider portal or fax to 877-486-2621

Step 2: Submit Complete Documentation

Required elements:

  • Completed prior authorization form
  • DMD genetic testing confirmation
  • Anti-AAV antibody results (<1:400)
  • Ambulatory status documentation
  • Medical necessity letter from specialist

Step 3: Humana Review Process

Standard timeline: 3-5 business days for standard review Expedited: 72 hours if medically urgent Contact: 800-555-CLIN (2546) for status updates

Step 4: Decision Notification

Approval: Authorization number provided for treatment scheduling Denial: Written explanation with specific reasons and appeal rights

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals that address payer-specific requirements.

Virginia DMD Centers for Administration

Certified Centers of Excellence

Children's Hospital of King's Daughters (CHKD) - Norfolk

  • MDA Care Center and PPMD Certified
  • Contact: [email protected] or (757) 668-9920
  • Specializes in Elevidys administration with full monitoring protocols

Children's Hospital of Richmond at VCU

  • MDA Care Center designation
  • PPMD Certified Duchenne Care Center
  • Comprehensive neuromuscular team

UVA Health Children's - Charlottesville

  • Pediatric neuromuscular specialists
  • Research-active DMD program
Important: Elevidys must be administered at a qualified center with appropriate monitoring capabilities for safety protocols.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Documentation Needed
Missing genetic confirmation Submit complete DMD gene test Genetic lab report with specific mutation
Anti-AAV titers too high Retest if recent; document timeline Lab results showing <1:400 titers
Non-ambulatory status Provide current mobility assessment Physical therapy/neurology notes
Age restriction Confirm patient meets 4+ requirement Birth certificate and medical records
Center not qualified Transfer to certified DMD center Referral to MDA/PPMD certified facility

Sample Medical Necessity Letter Points

Your specialist should address:

  • Confirmed DMD diagnosis with genetic testing
  • Current ambulatory function and prognosis
  • Anti-AAV antibody eligibility
  • Expected clinical benefit based on FDA approval
  • Safety monitoring plan at certified center

Appeals Process for Humana in Virginia

Internal Appeal (First Level)

Timeline: 65 days from denial notice for Medicare plans How to file: Call 1-800-833-6917 or submit via Humana member portal Required: Original denial letter, additional medical records, updated physician letter

External Review (Virginia State)

When to use: After internal appeal denial or if Humana fails to respond Timeline: 120 days from final denial to file Form 216-A Contact: Virginia SCC Bureau of Insurance at 1-877-310-6560

Virginia External Review Process:

  1. Complete Form 216-A (External Review Request)
  2. Mail to: SCC Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  3. Independent review by medical specialists
  4. Decision within 45 days (expedited available for urgent cases)
From our advocates: "We've seen Elevidys appeals succeed when families provide comprehensive genetic testing documentation and work closely with certified DMD centers to demonstrate clear medical necessity. The key is addressing each specific denial reason with clinical evidence."

Patient Phone Script for Appeal

"I'm calling to appeal the denial of Elevidys for my child with Duchenne muscular dystrophy. The denial reference number is [X]. We have new documentation from our DMD specialist at [center name] that addresses the denial reasons. Can you please start an expedited appeal and tell me exactly what additional information you need?"

Cost Considerations and Support

Humana Coverage Details

  • List price: Approximately $3.2 million for one-time treatment
  • Medicare Part B: 20% coinsurance after $283 deductible (2024)
  • Medicare Advantage: Out-of-pocket maximum typically $2,100-$8,850
  • Part D: Coverage varies; check formulary tier

Financial Assistance Options

  • Sarepta Patient Access Program: Contact 1-888-SAREPTA for eligibility
  • State pharmaceutical assistance programs
  • Charitable foundations for rare disease support

When working with insurance challenges, Counterforce Health helps families navigate complex prior authorization requirements and appeals processes for high-cost specialty medications like Elevidys.

FAQ: Elevidys Coverage Questions

Q: How long does Humana prior authorization take for Elevidys? A: Standard review is 3-5 business days, with expedited 72-hour review available for urgent medical situations.

Q: What if Elevidys is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Your DMD specialist can provide supporting clinical rationale.

Q: Can I get expedited appeals in Virginia? A: Yes, both Humana internal appeals and Virginia external review offer expedited processes when delay could jeopardize health.

Q: Do I need to use a specific DMD center? A: Most insurers require administration at certified centers of excellence. Virginia has three MDA/PPMD certified facilities.

Q: What happens if my anti-AAV antibodies are too high? A: Titers must be <1:400. If higher, discuss retesting timeline with your specialist, as levels can fluctuate.

Q: How do I track my appeal status? A: Use Humana's member portal or call 1-800-833-6917 with your reference number for real-time updates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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