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

How to Get Elevidys (Delandistrogene Moxeparvovec-Rokl) Covered by Humana in Michigan: Forms, Appeals, and State Protections

Quick Answer: Getting Elevidys Covered by Humana in Michigan

Elevidys requires prior authorization from Humana Medicare Advantage plans. Your fastest path: 1) Gather DMD genetic testing, prior steroid therapy records, and functional assessments; 2) Have your prescriber submit a complete PA request with medical necessity documentation; 3) If denied, file an internal appeal within 60 days, then request external review through Michigan DIFS within 127 days. Start today by calling Humana member services at the number on your insurance card to confirm PA requirements and request forms.

Table of Contents

Understanding Michigan's Insurance Appeal Rights

Michigan provides strong consumer protections through the Patient's Right to Independent Review Act (PRIRA), administered by the Department of Insurance and Financial Services (DIFS). Unlike many states, Michigan gives you 127 days (not the typical 120) to file an external appeal after your insurer's final denial.

Key Michigan protections:

  • External review by independent medical experts for medical necessity denials
  • Expedited review within 36 hours if delay would jeopardize your health
  • Binding decisions that insurers must follow
  • No cost to you for the external review process
Note: Michigan currently lacks state-mandated step therapy override protections, meaning Humana can require you to try other treatments first unless you meet their specific medical exception criteria.

Contact Michigan DIFS:

Humana's Prior Authorization Requirements

All gene therapies, including Elevidys, require prior authorization from Humana Medicare Advantage plans. Humana processes complete electronic requests within one business day for most drugs, but complex gene therapy reviews may take longer.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Mandatory for all gene therapies Humana PA Portal
Formulary Status Specialty tier (verify current placement) Humana Formulary Search
Site of Care Designated centers of excellence required Contact Humana clinical team
Age Requirements Per FDA label (ambulatory patients 4-5 years) FDA prescribing information
Genetic Testing Confirmed DMD mutation amenable to therapy Submit genetic test results

Step-by-Step: Fastest Path to Approval

1. Confirm Coverage and Requirements

Who: Patient or caregiver
Action: Call Humana member services
Timeline: Same day
Documents needed: Insurance card, member ID

2. Gather Clinical Documentation

Who: Healthcare team
Action: Collect all required medical records
Timeline: 1-2 weeks
Documents needed:

  • DMD genetic testing confirming eligible mutation
  • Functional assessments (6-minute walk test, North Star scores)
  • Prior corticosteroid therapy records
  • Liver function tests and cardiac evaluations
  • Anti-AAV antibody testing results

3. Submit Prior Authorization Request

Who: Prescribing physician
Action: Complete PA submission with supporting documentation
Timeline: Submit within 30 days of treatment plan
Portal: Humana Provider Portal

4. Medical Necessity Letter

Who: Treating neurologist or neuromuscular specialist
Action: Provide detailed clinical justification
Key elements:

  • DMD diagnosis with specific mutation
  • Current functional status and decline trajectory
  • Prior therapy trials and outcomes
  • Treatment goals and monitoring plan
  • Risk-benefit assessment

5. Follow Up and Track Status

Who: Patient/clinic staff
Action: Monitor PA status and respond to requests
Timeline: Check every 2-3 business days
Contact: Humana clinical pharmacy team

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing genetic confirmation Submit complete genetic testing report showing DMD mutation amenable to delandistrogene moxeparvovec
Patient not ambulatory Provide recent functional assessments (6MWT, North Star) documenting current ambulatory status
Elevated anti-AAV antibodies Submit recent antibody titers; if elevated, provide clinical rationale for proceeding
Inadequate steroid prophylaxis plan Detail corticosteroid regimen per protocol; include hepatic monitoring schedule
Center not designated Confirm treatment at Humana-approved center of excellence; request network exception if needed

Appeals Playbook for Michigan Patients

Internal Appeal (Level 1)

Deadline: 60 days from denial notice
Timeline: Humana has 30 days to decide (7 days for expedited)
How to file: Humana member portal or written request
Include: Original denial letter, additional medical records, updated physician letter

External Review (Michigan DIFS)

Deadline: 127 days from final internal denial
Timeline: 60 days for standard review (36 hours for expedited)
How to file: DIFS External Review Form
Cost: Free to patient

From our advocates: We've seen Michigan families succeed by submitting comprehensive genetic testing reports upfront and ensuring their neurologist explicitly addresses why Elevidys is medically necessary compared to standard supportive care. The key is showing functional decline despite optimal medical management.

When to Request Expedited Review

Request expedited processing if:

  • Patient's condition is rapidly declining
  • Delay would significantly impact functional outcomes
  • Standard timeline would miss optimal treatment window

Required: Physician letter stating that delay would jeopardize the patient's health or ability to regain maximum function.

Michigan expedited timeline: DIFS must complete review within 36 hours of receiving the request.

Continuity of Care During Plan Changes

If you're switching insurance plans while pursuing Elevidys coverage:

For MI Health Link enrollees: 90-180 day continuity period where new plan must honor existing prior authorizations

For commercial plan changes: Contact new insurer immediately to request continuity of care protections

Action steps:

  1. Notify new insurer of ongoing specialty therapy needs
  2. Request provider network exception if needed
  3. Submit documentation of current treatment plan
  4. File continuity of care appeal if coverage is disrupted

Scripts & Templates

Patient Phone Script for Humana

"I'm calling about prior authorization for Elevidys, generic name delandistrogene moxeparvovec-rokl, for my child with Duchenne muscular dystrophy. Can you please confirm the PA requirements, provide the forms, and give me the clinical contact for gene therapy reviews?"

Medical Necessity Letter Template

"[Patient] has genetically confirmed Duchenne muscular dystrophy with [specific mutation]. Despite optimal corticosteroid therapy with [drug, dose, duration], functional assessments show [specific decline metrics]. Elevidys is medically necessary because [clinical rationale]. All formulary alternatives [explain why inadequate]. Treatment goals include [specific functional outcomes]."

Costs & Financial Assistance

Elevidys list price: Approximately $3.2 million for one-time treatment

Financial support options:

  • Sarepta Patient Services (verify current link)
  • CureDuchenne financial assistance programs
  • State pharmaceutical assistance programs
  • Hospital charity care programs

Medicare coverage: If approved, Medicare Advantage typically covers at specialty tier cost-sharing levels.

Frequently Asked Questions

How long does Humana prior authorization take for Elevidys?
Standard PA decisions are made within 30 days for Medicare Advantage. Complex gene therapy reviews may require additional clinical consultation.

What if Elevidys isn't on Humana's formulary?
You can request a formulary exception with supporting medical necessity documentation. Specialty tier drugs cannot receive tiering exceptions for lower cost-sharing.

Can I appeal if Humana requires step therapy?
Yes, but Michigan lacks state-mandated step therapy override protections. You must meet Humana's specific medical exception criteria.

What happens if I miss the appeal deadline?
Michigan gives you 127 days for external review - longer than most states. If you miss internal appeal deadlines, you may still be able to file directly for external review in some cases.

Does insurance cover treatment at any hospital?
Gene therapies typically require treatment at designated centers of excellence. Confirm your preferred facility is in Humana's approved network.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes for medications like Elevidys. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that turn insurance denials into approvals. By identifying the specific denial basis and crafting point-by-point rebuttals aligned to each plan's requirements, we help families access life-changing treatments more efficiently.

For personalized assistance with your Elevidys appeal, visit www.counterforcehealth.org to learn how our platform can help strengthen your case with the right clinical evidence and payer-specific documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances, plan terms, and medical necessity determinations. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and requirements may change; verify current information with official sources.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.