By Counterforce Health Team in Eloctate (coagulation factor VIII, rFVIIIFc; efmoroctocog alfa) —

How to Get Eloctate Covered by Humana in Florida: Prior Authorization Forms, Appeals, and Medical Necessity Letters

Answer Box: Getting Eloctate Covered by Humana in Florida

Eloctate (efmoroctocog alfa) requires prior authorization from Humana in Florida. The fastest path to approval: 1) Have your hematologist submit Humana's PA form with complete clinical documentation, 2) Include medical necessity letter showing hemophilia A diagnosis and failed alternatives, 3) Use CenterWell Specialty Pharmacy for dispensing. Start today by downloading the current PA form from Humana's provider portal. Appeals must be filed within 65 days of denial for Medicare plans.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding and Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & Solutions
  10. Appeals Process in Florida
  11. Frequently Asked Questions
  12. Printable Checklist

Who Should Use This Guide

This comprehensive checklist helps patients with hemophilia A and their healthcare providers navigate Humana's prior authorization process for Eloctate (efmoroctocog alfa, coagulation factor VIII) in Florida. You'll need this if:

  • Your doctor prescribed Eloctate for hemophilia A treatment
  • You have Humana Medicare Advantage, Medicare Part D, or Medicaid coverage in Florida
  • You received a denial and need to file an appeal
  • You want to prevent common approval delays

Expected outcome: With complete documentation, most medically appropriate requests are approved within 7-30 days. Denials can often be overturned through appeals when proper clinical justification is provided.

Member & Plan Basics

Active Coverage Verification

Before starting the PA process, confirm your Humana coverage details:

  • Member ID and plan type (Medicare Advantage, Part D, Medicaid)
  • Active enrollment status through Humana member portal
  • Specialty pharmacy benefits and preferred vendors
  • Annual deductible status and out-of-pocket maximums

Plan-Specific Requirements

Medicare Advantage/Part D: Eloctate requires prior authorization under Humana's Medicare Advantage formulary. The drug is considered preferred for hemophilia A without inhibitors as of 2025.

Medicaid: Florida Humana Healthy Horizons covers Eloctate through their Preferred Drug List at no cost when approved, but PA is mandatory.

Clinical Criteria for Approval

Primary Indication Requirements

Eloctate is approved by Humana for:

  • Hemophilia A (hereditary factor VIII deficiency) - ICD-10 code D66
  • On-demand treatment of bleeding episodes
  • Perioperative management of bleeding
  • Routine prophylaxis to prevent bleeding episodes
Important: Eloctate is NOT indicated for von Willebrand disease. Using it off-label may result in automatic denial.

Step Therapy Considerations

According to Humana's 2025 Part B Step Therapy Preferred Drug List, Eloctate (J7205) is listed as a preferred product alongside Adynovate, Jivi, and Altuviiio. This means:

  • No step therapy required if prescribing Eloctate as first-line treatment
  • Documentation needed if switching from another preferred FVIII product
  • Prior failure documentation required only for non-preferred alternatives

Dosing and Duration Guidelines

Prophylaxis: Standard dosing is 50 IU/kg every 4 days, individualized based on:

  • Patient weight and pharmacokinetics
  • Bleeding phenotype and history
  • Physical activity level
  • Target joint involvement

On-demand: Typical doses range from 27-32 IU/kg per bleeding episode, adjusted for severity.

Coding and Billing Requirements

HCPCS and ICD-10 Codes

Code Type Code Description Billing Unit
HCPCS J-code J7205 Eloctate (antihemophilic factor, recombinant, Fc fusion) 1 IU per unit
ICD-10 Primary D66 Hereditary factor VIII deficiency -
Modifier (if required) JA Intravenous infusion -

NDC Requirements

Humana may require the 11-digit National Drug Code (NDC) on claims. Common Eloctate vial sizes include:

  • 250 IU, 500 IU, 750 IU, 1000 IU
  • 1500 IU, 2000 IU, 3000 IU, 4000 IU
  • 5000 IU, 6000 IU

Billing tip: Report the exact IU administered (e.g., J7205 x1500 for 1500 IU dose). Don't mix vial sizes on a single claim line.

Documentation Packet

Provider Note Elements

Your hematologist's clinical note must include:

Diagnosis confirmation:

  • Factor VIII activity level (typically <1% for severe, 1-5% for moderate)
  • Genetic testing results if available
  • Family history of bleeding disorders

Bleeding history:

  • Annualized bleeding rate over past 12 months
  • Location and severity of bleeding episodes
  • Target joint identification and imaging if applicable
  • Impact on quality of life, school, or work

Prior treatment history:

  • Previous factor VIII products tried
  • Outcomes, failures, or adverse reactions
  • Reasons for switching to Eloctate (if applicable)

Medical Necessity Letter Components

A strong medical necessity letter should address:

  1. Patient-specific factors: Age, weight, activity level, bleeding phenotype
  2. Clinical rationale: Why Eloctate is preferred over alternatives
  3. Dosing justification: Proposed regimen and monitoring plan
  4. Treatment goals: Specific outcomes expected (reduced bleeding, improved QOL)
  5. Supporting evidence: Guidelines, studies, or clinical experience
From our advocates: We've seen the strongest approvals when providers include specific bleeding diary data showing frequency and severity of episodes, along with clear documentation of how previous treatments failed to prevent target joint bleeds. This concrete evidence helps reviewers understand why the extended half-life of Eloctate is medically necessary.

Required Attachments

  • Recent factor VIII activity assays
  • Bleeding diary or episode log (past 6-12 months)
  • Imaging of affected joints (if applicable)
  • Prior authorization denials for other products (if relevant)
  • Pharmacokinetic study results (if performed)

Submission Process

Correct Form Version

Use Humana's current prior authorization forms:

Critical: Form versions change annually. Always download the most current version to avoid automatic rejections.

Submission Methods

Preferred: Humana provider portal with electronic submission Alternative: Fax to 877-486-2621 (verify current number on form) Phone: 1-800-281-6918 for urgent requests or clarification

Required Fields That Cause Rejections

Common incomplete fields that delay approval:

  • Patient weight and calculated dosing
  • Specific ICD-10 diagnosis codes
  • Prescriber NPI and specialty designation
  • Prior therapy details with dates and outcomes
  • Requested quantity and days supply

Specialty Pharmacy Requirements

Preferred Vendor Network

Humana strongly prefers CenterWell Specialty Pharmacy for Eloctate dispensing. Benefits include:

  • Integrated PA processing
  • Clinical support and adherence monitoring
  • Temperature-controlled shipping to Florida addresses
  • Financial assistance program coordination

Transfer Process

If currently using another specialty pharmacy:

  1. Contact CenterWell at 1-800-486-2668
  2. Provide current prescription and insurance information
  3. Authorize prescription transfer from current pharmacy
  4. Confirm Florida shipping address and delivery preferences

After Submission: What to Expect

Timeline and Status Tracking

Request Type Standard Timeline Expedited Timeline
Standard PA 7-14 business days 72 hours
Medicare Part D Up to 72 hours 24 hours
Appeals 30-60 days 72 hours

Status checking: Use Humana's provider portal or call 1-800-281-6918 with PA reference number.

Confirmation Documentation

Save these important items:

  • PA reference/confirmation number
  • Submission date and method
  • Assigned reviewer contact information
  • Expected decision date
  • All correspondence and phone call logs

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Non-preferred product Submit formulary exception request Medical necessity letter explaining why preferred alternatives failed
Insufficient medical necessity Provide detailed bleeding history Bleeding diary, factor levels, prior treatment failures
Dosing exceeds limits Submit pharmacokinetic justification PK study results or breakthrough bleeding documentation
Wrong prescriber specialty Transfer to hematologist Referral to hemophilia treatment center
Missing prior authorization Resubmit with complete form All required fields and attachments

Counterforce Health can help streamline this process by analyzing your denial letter and generating targeted, evidence-backed appeals that address specific payer requirements. Their platform identifies the exact denial basis and crafts point-by-point rebuttals using the right clinical evidence and payer-specific language.

Appeals Process in Florida

Internal Appeals (First Level)

Timeline: 65 days from denial notice for Medicare plans Submission: Online portal, fax to 877-486-2621, or mail Required: Completed appeal form, additional clinical documentation, provider letter

External Review (Second Level)

If internal appeal is denied, you have rights under Florida law:

Expedited Appeals

For urgent medical situations:

  • Timeline: 72 hours for decision
  • Eligibility: Serious jeopardy to health or life
  • Process: Call Humana immediately at 1-800-281-6918

Frequently Asked Questions

How long does Humana prior authorization take for Eloctate in Florida? Standard requests take 7-14 business days. Expedited requests are decided within 72 hours for urgent medical needs.

What if Eloctate is non-formulary on my plan? Submit a formulary exception request with medical necessity documentation showing why preferred alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if you can demonstrate that waiting for standard appeal timelines would seriously jeopardize your health.

Does step therapy apply if I've used FVIII products outside Florida? Prior treatment history from any state counts toward step therapy requirements. Provide complete documentation of previous therapies.

What's the difference between Medicare and Medicaid coverage? Medicare typically has cost-sharing requirements, while Florida Medicaid covers approved medications at no cost to the member.

How do I find a hemophilia specialist in Florida? Contact the National Hemophilia Foundation for Florida hemophilia treatment center locations.

Printable Checklist

Before Starting:

  • Verify active Humana coverage and plan type
  • Confirm hemophilia A diagnosis with factor VIII levels
  • Gather 12 months of bleeding episode documentation
  • Collect prior treatment history and outcomes

Clinical Requirements:

  • ICD-10 code D66 (hereditary factor VIII deficiency)
  • Hematologist prescription and evaluation
  • Dosing plan (prophylaxis: ~50 IU/kg q4d; on-demand: 27-32 IU/kg)
  • Medical necessity letter addressing specific clinical need

Submission Packet:

  • Current Humana PA form (verify version date)
  • Complete provider clinical note
  • Factor VIII activity levels
  • Bleeding diary or episode log
  • Prior treatment documentation
  • Joint imaging (if applicable)

After Submission:

  • PA reference number recorded
  • Status check scheduled (7-10 days)
  • CenterWell Specialty Pharmacy contacted
  • Appeal timeline noted (65 days for Medicare)

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult your healthcare provider and insurance plan documents for personalized guidance.

For assistance with insurance complaints in Florida, contact the Florida Department of Financial Services Consumer Helpline at 1-877-MY-FL-CFO (1-877-693-5236).

Sources & Further Reading

Whether you're facing an initial denial or planning ahead for approval, Counterforce Health offers specialized support for complex specialty drug authorizations, turning insurance challenges into successful outcomes through targeted, evidence-based appeals.

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