Does Eloctate require prior authorization with Humana in Texas?

Yes, Eloctate (efmoroctocog alfa) requires prior authorization from Humana in Texas for all plan types. This is because it's a specialty medication for hemophilia A treatment.

How long does Humana take to approve Eloctate prior authorization?

Standard prior authorization requests take up to 14 days for approval. Urgent requests can be processed within 72 hours if properly documented as medically necessary.

What documentation is needed for Eloctate prior authorization with Humana?

Required documentation includes: hemophilia A diagnosis, factor VIII levels, bleeding history, previous treatments tried, and clinical justification for why preferred alternatives are not suitable.

Can I appeal if Humana denies Eloctate coverage?

Yes, you have the right to appeal Humana's denial. The appeal process typically allows 60 days from the denial date to submit additional clinical evidence and documentation.

Which specialty pharmacies does Humana use for Eloctate in Texas?

Humana typically requires Eloctate to be dispensed through their contracted specialty pharmacy network. Contact Humana member services to confirm which specialty pharmacies are in-network for your specific plan.

By Counterforce Health Team in Eloctate (coagulation factor VIII, rFVIIIFc; efmoroctocog alfa) — 30 Sep 2025

How to Get Eloctate Covered by Humana in Texas: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Eloctate Covered by Humana in Texas

Eloctate (efmoroctocog alfa) requires prior authorization from Humana in Texas for all plan types. The fastest path: Have your hematologist submit a PA request with complete clinical documentation via Humana's provider portal or fax to 877-486-2621. Include diagnosis, factor VIII levels, bleeding history, and why preferred alternatives aren't suitable. Standard approval takes 7-30 days; expedited requests get 24-72 hour decisions. If denied, you have 65 days to appeal through Humana's internal process, followed by external review through Texas Department of Insurance if needed.

Start Here: Verify Your Plan and Requirements
Forms and Documentation Needed
Submission Portals and Methods
Specialty Pharmacy Requirements
Appeals Process in Texas
Common Denial Reasons and Solutions
Support Contacts and Resources
Timeline and Next Steps

Start Here: Verify Your Plan and Requirements

Before requesting Eloctate coverage, confirm your specific Humana plan type, as requirements vary:

Medicare Advantage (Part C): Prior authorization required for all factor VIII products. Standard decisions within 30 days, expedited within 72 hours.

Medicare Part D: Formulary exception may be needed if Eloctate is non-preferred. Appeals follow Part D timelines (7 days standard, 24 hours expedited).

Commercial Plans: PA requirements vary by employer group. Check your Summary of Benefits or call member services at (866) 396-8810.

Tip: Have your member ID ready and ask specifically about "factor VIII prior authorization requirements" when calling.

Coverage at a Glance

Requirement	What It Means	Where to Find It	Source
Prior Authorization	Clinical review required before coverage	Humana PA Lists	Humana Provider Manual
Specialty Pharmacy	Must use in-network specialty pharmacy	CenterWell Specialty	Humana Pharmacy Network
Medical Necessity	Documented clinical need for Eloctate specifically	Provider clinical notes	PA Policy Requirements
Appeals Deadline	65 days from denial notice	Member Appeals	CMS Guidelines

Forms and Documentation Needed

Required Forms

Prior Authorization Request Form: Download from Humana's provider portal or request by calling 800-555-2546
Medicare Coverage Determination Form: For Part D plans, available at Humana member portal
Letter of Medical Necessity: Provider-written clinical justification

Clinical Documentation Checklist

Your hematologist should include:

✅ Primary diagnosis (Hemophilia A with ICD-10 code)
✅ Current factor VIII level and bleeding history
✅ Prior factor VIII products tried and outcomes
✅ Specific contraindications to preferred alternatives
✅ Proposed dosing schedule (e.g., 50 IU/kg every 4 days)
✅ Treatment goals and monitoring plan

Clinician Corner: Reference FDA labeling and National Hemophilia Foundation guidelines in your medical necessity letter. Include specific bleeding episode documentation and factor recovery studies if available.

Submission Portals and Methods

Electronic Submission (Preferred)

Provider Portal: Availity.com for transactional PA requests
Humana Provider Portal: Direct submission at provider.humana.com
Timeline: Electronic submissions must include all clinical data within 30 days of service date

Fax Submission

Standard PA Requests: 877-486-2621
Expedited Requests: 1-800-949-2961
Medication Intake Team: 1-888-447-XXXX (verify current number with Humana)

Phone Submission

Clinical Review Line: 800-555-2546 (Monday-Friday, 8 AM-8 PM local time)
Member Services: (866) 396-8810 for status updates

Note: Include a cover sheet with member ID, provider NPI, and "FACTOR VIII PRIOR AUTHORIZATION" clearly marked.

Specialty Pharmacy Requirements

Eloctate must be dispensed through Humana's specialty pharmacy network for coverage.

Primary Specialty Pharmacy

CenterWell Specialty Pharmacy (Humana-owned)

Phone: 1-800-486-2668 (TTY: 711)
Transfer Fax: 1-877-405-7940
Services: Home infusion coordination, nursing support, financial assistance

Transfer Process

Contact CenterWell to initiate prescription transfer
Authorize transfer from your current pharmacy
Verify prior authorization is active before first fill
Schedule delivery and home infusion if needed

Counterforce Health helps patients navigate specialty pharmacy transfers and ensures all documentation requirements are met for smooth transitions between providers.

Appeals Process in Texas

Internal Appeal (Required First Step)

Deadline: 65 days from denial notice
Method: Submit via Humana appeals portal or mail to: Humana, P.O. Box 14168, Lexington, KY 40512-4168
Timeline: 7 days for Part D, 30 days for Medicare Advantage
Expedited: 24-72 hours if delay would jeopardize health

External Review (Texas Independent Review)

If Humana denies your internal appeal, Texas law provides additional protection:

Eligibility: Medical necessity denials for state-regulated plans
Deadline: 4 months from final internal denial
Process: Texas Department of Insurance contracts Independent Review Organizations (IROs)
Timeline: 20 days standard, 5 days for urgent cases
Cost: Free to patient (insurer pays IRO fees)

Important: ERISA self-funded plans, Medicare, and Medicaid follow federal appeal rules, not Texas IRO process.

Texas Resources for Appeals Help

Texas Department of Insurance: 1-800-252-3439
Office of Public Insurance Counsel: 1-877-611-6742
IRO Information Line: 1-866-554-4926

Common Denial Reasons and Solutions

Denial Reason	Solution Strategy	Required Documentation
Non-preferred brand	Submit formulary exception with medical necessity letter	Prior therapy failures, contraindications to preferred options
Quantity/dose limits	Provide weight-based dosing justification	Patient weight, pharmacokinetic studies, bleeding frequency
Not prescribed by specialist	Transfer prescription to hematologist	Referral to hemophilia treatment center
Insufficient trial of preferred therapy	Document failed step therapy	Treatment records, adverse events, efficacy data
Site of care restriction	Justify home infusion necessity	Patient mobility, venous access, infection risk factors

Sample Phone Script for Members

"I'm calling about prior authorization for Eloctate for my hemophilia A. My member ID is [NUMBER]. My hematologist submitted the request on [DATE], and I need to check the status. Can you also confirm if any additional documentation is needed?"

Support Contacts and Resources

Humana Member Services

Primary: (866) 396-8810 (Monday-Friday, 8 AM-9 PM ET)
TTY: 711
Specialty Drug Case Management: Request transfer to hemophilia support team
Written Correspondence: Humana, P.O. Box 14168, Lexington, KY 40512-4168

Provider Support

Prior Authorization: 800-555-2546
Peer-to-Peer Review: Request during PA denial
Clinical Pharmacy Review Team: Available for complex cases

Financial Assistance

Sobi Cares Patient Assistance: eloctatepro.com (verify current program details)
Humana Pharmacy Solutions: Copay assistance programs for eligible members

Timeline and Next Steps

Standard Process Timeline

Day 0: Provider submits PA request
Day 1-7: Humana clinical review (Part D)
Day 7-30: Decision notification (Medicare Advantage)
Day 31-95: Internal appeal period (if denied)
Day 96-216: External review period (Texas plans)

Immediate Action Items

Verify your Humana plan type and formulary status
Schedule appointment with hematologist for PA submission
Gather complete medical records and prior therapy documentation
Contact CenterWell Specialty Pharmacy to establish account
Set up tracking for PA status and appeal deadlines

From Our Advocates: We've seen the fastest approvals when patients work closely with their hemophilia treatment center's social worker or case manager. These professionals know exactly what documentation Humana requires and can expedite the submission process. Having all medical records organized before the first PA submission saves weeks of back-and-forth requests.

When facing a complex prior authorization process, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with payer requirements, helping patients get critical medications like Eloctate approved faster.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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