By Counterforce Health Team in Emflaza (deflazacort) —

How to Get Emflaza (Deflazacort) Covered by Humana in California: Complete Coding, Prior Authorization & Appeals Guide

Answer Box: Getting Emflaza Covered by Humana in California

Emflaza (deflazacort) requires prior authorization from Humana and uses ICD-10 code G71.01 for Duchenne muscular dystrophy. Most approvals require documented failure of prednisone due to weight gain or behavioral issues. If denied, California residents can appeal through Humana's internal process (65 days), then file for Independent Medical Review (IMR) through the DMHC within 6 months. First step today: Have your neurologist document prednisone intolerance and submit PA through Humana's provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for DMD Documentation
  3. Product Coding: NDC, HCPCS, and Billing Units
  4. Clean Prior Authorization Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification with Humana Resources
  7. Appeals Playbook for California
  8. Quick Pre-Submission Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Emflaza (deflazacort) typically follows the pharmacy benefit pathway with Humana Medicare Advantage plans, but understanding both options helps ensure proper billing and approval.

Pharmacy Benefit (Most Common)

  • Primary codes: NDC numbers for tablets and oral suspension
  • Submission: Through pharmacy with prior authorization
  • Advantage: Standard pharmacy copays; familiar workflow for patients

Medical Benefit (Less Common)

  • Primary codes: HCPCS J3490 (unclassified drugs) with ICD-10 G71.01
  • Submission: Through medical claims with units calculation
  • When used: Clinic administration or specific plan requirements
Tip: Most Humana plans prefer pharmacy benefit billing for Emflaza. Check your specific plan's preferred pathway through the provider portal.

ICD-10 Mapping for DMD Documentation

The ICD-10 code G71.01 specifically designates Duchenne or Becker muscular dystrophy and became effective October 1, 2018. This dedicated code is crucial for reimbursement access, as noted by Patient advocacy organizations.

Documentation Requirements for G71.01

Your medical records must support the diagnosis with:

  • Genetic testing results showing dystrophin gene mutation
  • Clinical presentation with weakness onset before age 5
  • Specialist involvement (neurologist experienced in DMD treatment)
  • Functional assessments (6-minute walk test, North Star Ambulatory Assessment)

Supporting Documentation Language

Include these phrases in clinical notes to strengthen coding:

  • "Confirmed Duchenne muscular dystrophy via genetic testing"
  • "Progressive muscle weakness consistent with DMD phenotype"
  • "Failed prednisone therapy due to [specific adverse effects]"
  • "Requires alternative corticosteroid for DMD management"

Product Coding: NDC, HCPCS, and Billing Units

NDC Codes for Emflaza

Product Form NDC Number Package Size Billing Notes
Tablets 52856-501-01 100-count bottle Most common; various strengths available
Oral Suspension 71863-123-01 Liquid formulation For patients unable to swallow tablets

HCPCS Coding (Medical Benefit)

When billing through medical benefit:

  • Primary code: J3490 (unclassified drugs)
  • ICD-10: G71.01 (Duchenne or Becker muscular dystrophy)
  • Units calculation: Based on actual dose administered
  • Documentation: Include drug name, strength, and medical necessity
Note: Emflaza lacks a specific J-code, so J3490 serves as the unclassified drug designation for medical benefit claims.

Clean Prior Authorization Anatomy

Essential Elements for Humana PA

Patient Information:

  • Humana member ID and plan details
  • Patient age (must be ≥2 years for Emflaza)
  • Primary diagnosis: G71.01

Clinical Documentation:

  • Genetic testing confirming dystrophin mutation
  • Chart notes showing weakness onset before age 5
  • Prescriber: Neurologist experienced in DMD

Step Therapy Documentation:

  • Option A: Prednisone trial ≥6 months with documented adverse effects (Cushingoid appearance, central obesity, ≥10% weight gain)
  • Option B: Behavioral issues during prednisone therapy (aggression, abnormal behavior persisting >6 weeks)

Safety Requirements:

  • Absence of active infections (TB, Hepatitis B)
  • No concurrent live vaccinations planned
  • Dosing per FDA-approved labeling

Counterforce Health helps patients and clinicians streamline this documentation process by automatically generating evidence-backed appeals that align with payer-specific requirements like Humana's step therapy criteria.

Frequent Coding and Billing Pitfalls

Common Mistakes to Avoid

1. Incorrect ICD-10 Usage

  • ❌ Using generic muscular dystrophy codes
  • ✅ Specific G71.01 for Duchenne/Becker MD

2. Incomplete Step Therapy Documentation

  • ❌ "Patient tried prednisone"
  • ✅ "Patient experienced 15% weight gain over 6 months on prednisone 0.75 mg/kg/day"

3. Missing Specialist Requirement

  • ❌ Primary care physician prescription
  • ✅ Neurologist with DMD experience

4. Inadequate Medical Necessity

  • ❌ General steroid request
  • ✅ Specific alternative to failed prednisone therapy

Units Calculation for J3490

When using medical benefit billing:

  • Calculate based on actual dose administered
  • Include drug name in claim description
  • Document administration route and frequency

Verification with Humana Resources

Pre-Submission Verification Steps

1. Confirm Current Formulary Status

2. Review Plan-Specific Requirements

  • Access MyHumana member portal for exact coverage details
  • Contact Customer Care number on member ID card
  • Confirm tier placement and estimated costs

3. Provider Portal Verification

  • Use Humana provider portal for real-time PA status
  • Submit electronic PA when possible for faster processing
  • Track submission and response timelines

Cross-Reference Checklist

Before submitting, verify:

  • NDC matches prescribed formulation
  • ICD-10 G71.01 supports medical necessity
  • Step therapy documentation is complete
  • Prescriber meets specialist requirements
  • All safety exclusions addressed

Appeals Playbook for California

Humana Internal Appeals Process

Timeline: 65 days from denial notice to submit internal appeal

Standard Decision: Up to 14 calendar days (reducing to 7 days in January 2026)

Expedited Decision: 72 hours with prescriber attestation of urgent need

Submission Methods:

  • Provider portal (preferred)
  • Fax: 877-486-2621 (verify current number)
  • Mail to address on denial letter

Required Documentation for Appeals

Include with your appeal:

  • Original denial letter
  • Updated clinical notes
  • Prescriber letter explaining medical necessity
  • Evidence of prednisone failure/intolerance
  • Recent functional assessments (6MWT, NSAA scores)
  • Any new supporting literature

California Independent Medical Review (IMR)

If Humana upholds the denial, California residents can request external review through the Department of Managed Health Care (DMHC).

Filing Deadline: Within 6 months of Humana's final internal decision

Timeline:

  • Standard IMR: 45 days
  • Expedited IMR: 72 hours

How to File:

Success Factors: California has high IMR approval rates for medically necessary specialty drugs when supported by proper documentation.

From our advocates: We've seen DMD families succeed with IMR by including detailed functional decline documentation and peer-reviewed studies showing deflazacort's superior side effect profile compared to prednisone. The key is demonstrating that Emflaza isn't just preferred—it's medically necessary for this specific patient's circumstances.

Quick Pre-Submission Checklist

Before Submitting PA or Appeal

Patient Eligibility:

  • Age ≥2 years
  • Confirmed DMD diagnosis with genetic testing
  • Humana Medicare Advantage member in good standing

Clinical Documentation:

  • ICD-10 G71.01 properly coded
  • Neurologist prescription/consultation documented
  • Step therapy requirements met (prednisone failure documented)
  • Dosing per FDA labeling
  • Safety exclusions addressed

Administrative Requirements:

  • Correct NDC or HCPCS codes used
  • Prior authorization form complete
  • All supporting documents attached
  • Submission method confirmed (portal preferred)

Appeal-Specific Items (if applicable):

  • Filed within 65-day deadline
  • Original denial letter included
  • New supporting evidence provided
  • Clear medical necessity argument

Cost and Coverage Considerations

Humana Coverage: Emflaza has been on Humana's formulary since January 1, 2020, with regular policy updates. Prior authorization is required with step therapy requirements.

Out-of-Pocket Costs: Vary by plan tier and deductible status. Medicare's 2025-2026 Part D out-of-pocket maximum is $2,000.

Manufacturer Support: PTC Therapeutics offers patient assistance programs on a case-by-case basis. Contact their patient support team for eligibility screening.

When All Else Fails

If both internal appeals and IMR are unsuccessful, consider:

Legal Resources: California legal aid organizations can help with complex cases State Advocacy: Contact the DMHC Help Center for additional guidance Alternative Coverage: Explore Medicare Part D plan changes during Open Enrollment (October 15 - December 7)

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed rebuttals that align with each payer's specific requirements—helping patients navigate complex prior authorization processes like Humana's step therapy requirements for Emflaza.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance policies and coverage requirements change frequently. Always verify current requirements with Humana and consult with your healthcare provider for medical decisions. For assistance with insurance appeals and coverage issues in California, contact the DMHC Help Center at 888-466-2219.

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