By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (Etanercept) Covered by Humana in Georgia: Prior Authorization, Appeals, and Medical Necessity Requirements

Answer Box: Getting Enbrel Covered by Humana in Georgia

Humana requires prior authorization and step therapy for Enbrel (etanercept) in Georgia. You must try preferred alternatives first, provide TB screening within 12 months, and document medical necessity through a specialist. If denied, you have 65 days to appeal internally, then 60 days for Georgia's external review.

Fastest path to approval:

  1. Get specialist evaluation (rheumatologist/dermatologist)
  2. Document failed conventional therapies (methotrexate, etc.)
  3. Complete TB screening and submit PA request
  4. If denied, file internal appeal within 65 days

Start today: Contact your prescriber to initiate the prior authorization process through Humana's provider portal.

Table of Contents

  1. Humana's Coverage Policy Overview
  2. Medical Necessity Requirements
  3. Step Therapy and Exception Pathways
  4. Quantity Limits and Renewal Requirements
  5. Required Diagnostics and Testing
  6. Specialty Pharmacy Requirements
  7. Evidence to Support Medical Necessity
  8. Sample Medical Necessity Letter
  9. Appeals Process in Georgia
  10. Common Denial Reasons and Solutions
  11. Costs and Patient Assistance
  12. FAQ

Humana's Coverage Policy Overview

Humana covers Enbrel (etanercept) across its Medicare Advantage, Medicare Part D, and employer group plans, but with significant restrictions. The drug is classified as a specialty-tier medication requiring both prior authorization and step therapy compliance.

Plan Types and Coverage Variations

  • Medicare Advantage/Part D: Enbrel typically sits on Tier 5 (Specialty), requiring higher coinsurance
  • Employer Group Plans: Coverage varies by employer but generally follows similar PA requirements
  • Medicaid Plans: Limited Humana Medicaid presence in Georgia; most coverage through Wellcare (Centene)
Note: Coverage details can change annually on January 1st. Always verify current formulary status through Humana's drug list tool.

Medical Necessity Requirements

Humana covers Enbrel for FDA-approved indications when medical necessity is established:

Approved Conditions

  • Moderate to severe rheumatoid arthritis
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Moderate to severe plaque psoriasis
  • Polyarticular juvenile idiopathic arthritis

Specialist Requirement

Coverage requires evaluation and ongoing care by an appropriate specialist:

  • Rheumatoid arthritis/psoriatic arthritis/ankylosing spondylitis: Rheumatologist
  • Plaque psoriasis: Dermatologist or rheumatologist
  • Juvenile conditions: Pediatric rheumatologist

Step Therapy and Exception Pathways

Before approving Enbrel, Humana requires documented failure, intolerance, or contraindication to preferred alternatives.

Required Prior Therapies

For Rheumatoid Arthritis:

  • At least one conventional DMARD (typically methotrexate) for minimum 2-3 months
  • Documentation of inadequate response or intolerance
  • May require corticosteroid trial

For Plaque Psoriasis:

  • Topical therapies (corticosteroids, vitamin D analogs)
  • Systemic therapy (methotrexate, cyclosporine) if moderate to severe
  • Phototherapy documentation may be required

Medical Exception Documentation

To bypass step therapy, provide:

  • Clinical notes detailing contraindications to required therapies
  • Allergy documentation or previous serious adverse events
  • Drug interaction concerns with current medications
  • Specialist statement explaining why alternatives aren't appropriate
From our advocates: We've seen successful step therapy exceptions when prescribers clearly document specific contraindications—like methotrexate being contraindicated due to liver disease—rather than general statements about patient preference.

Quantity Limits and Renewal Requirements

Dispensing Restrictions

  • 30-day supply limit per fill
  • Must use Humana-authorized specialty pharmacy
  • No 90-day supplies available for Enbrel

Renewal Process

  • Initial approvals typically 6 months
  • Renewals require documented clinical response
  • Annual reassessment of medical necessity
  • Lab monitoring results must be current

Required Diagnostics and Testing

Mandatory TB Screening

Within 12 months of initiation:

  • Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)
  • Chest X-ray
  • Review of TB risk factors and exposure history

Positive screening requires:

  • Infectious disease consultation
  • Treatment of latent TB before Enbrel initiation
  • Documentation of completed anti-TB therapy

Additional Laboratory Requirements

  • Complete blood count with differential
  • Liver function tests
  • Hepatitis B and C screening
  • Assessment for active infections
Tip: Schedule TB testing immediately when considering Enbrel—the 12-month window is strictly enforced, and delays in testing commonly cause PA denials.

Specialty Pharmacy Requirements

Humana mandates Enbrel dispensing through authorized specialty pharmacies due to storage and handling requirements.

Approved Specialty Pharmacies

  • Humana Pharmacy Solutions
  • Accredo (Cigna subsidiary)
  • CVS Specialty
  • Other contracted specialty pharmacies (verify with Humana)

What This Means for Patients

  • Cannot fill at regular retail pharmacies
  • Specialty pharmacy coordinates with prescriber for PA
  • Home delivery typically required
  • Enhanced patient support and monitoring services

Evidence to Support Medical Necessity

Clinical Guidelines to Reference

Required Clinical Documentation

  • Disease severity scores (DAS28 for RA, PASI for psoriasis, BASDAI for AS)
  • Functional assessment measures
  • Photographic documentation for psoriasis
  • Response to previous therapies with specific dates and outcomes

Sample Medical Necessity Letter

Template structure for prescribers:

"[Patient name] is a [age]-year-old with moderate to severe [condition] diagnosed on [date] by [specialist type]. Despite adequate trials of [list specific prior therapies with dates and durations], the patient continues to experience [specific symptoms/disease activity measures].

Previous therapies failed due to [inadequate response/intolerance—be specific]. Current disease activity is evidenced by [specific measures: DAS28 score, PASI score, etc.]. The patient has completed TB screening on [date] with negative results.

Based on [cite specific guidelines], Enbrel is medically necessary to achieve disease control and prevent irreversible joint damage. The patient will be monitored per FDA labeling with [specific monitoring plan]."

Appeals Process in Georgia

Internal Appeal Timeline

  • Filing deadline: 65 days from denial notice
  • Humana decision timeframe: 7 days standard, 72 hours expedited
  • Required documentation: Denial letter, medical records, prescriber statement

Georgia External Review

If Humana denies your internal appeal:

  • Filing deadline: 60 days from Humana's final denial
  • Process: Submit application to Georgia Department of Insurance
  • Timeline: 30 business days standard, 72 hours expedited
  • Cost: Free to consumers

How to File External Review

  1. Complete Georgia external review application (available on DOI website)
  2. Include all relevant medical documentation
  3. Submit to Georgia Office of Commissioner of Insurance and Fire Safety
  4. Call 1-800-656-2298 for assistance

For urgent medical situations, you can request expedited external review concurrent with internal appeals.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document prior therapy failures Medication history with dates, outcomes, reasons for discontinuation
Insufficient TB screening Complete required testing TB test results within 12 months, chest X-ray
Not medically necessary Provide clinical justification Disease activity scores, functional assessments, specialist evaluation
Quantity limit exceeded Request exception or adjust dosing Clinical rationale for higher quantity, prescriber statement
Non-formulary status Request formulary exception Medical necessity letter, failure of formulary alternatives

Costs and Patient Assistance

Manufacturer Support Programs

  • Enbrel Support: Copay assistance for eligible patients
  • Income-based assistance: Available through Amgen Safety Net Foundation
  • Free drug programs: For uninsured patients meeting income criteria

Georgia-Specific Resources

  • Georgia 211: Call 2-1-1 for local prescription assistance programs
  • NeedyMeds: Database of patient assistance programs
  • Georgians for a Healthy Future: Consumer advocacy and assistance

When navigating complex insurance approvals like this, specialized support can make a significant difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

FAQ

How long does Humana prior authorization take for Enbrel in Georgia? Standard PA decisions take up to 14 business days. Expedited requests (when medically urgent) must be decided within 72 hours.

What if Enbrel isn't on my Humana formulary? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. This requires prescriber documentation.

Can I appeal a Humana denial if I live in Georgia? Yes. You have 65 days for internal appeals with Humana, then 60 days for external review through the Georgia Department of Insurance.

Does step therapy apply if I've used Enbrel successfully in another state? Previous successful use can support a step therapy exception, but you'll need documentation of that treatment history and clinical response.

What's the difference between Enbrel and its biosimilars for coverage? Humana may prefer biosimilars (Erelzi, Eticovo) over brand-name Enbrel. Medical necessity for the brand requires documenting why biosimilars aren't appropriate.

Can I use GoodRx or other discount programs with Humana? Generally no—using discount programs instead of insurance may violate your plan terms. Use manufacturer copay assistance programs instead.

What if my doctor isn't a specialist but has been treating my condition? Humana typically requires specialist involvement for Enbrel approval. Your primary care doctor may need to refer you to a rheumatologist or dermatologist.

How often do I need to renew Enbrel authorization? Initial approvals are typically 6 months, with renewals possible for up to 1 year based on documented clinical response and ongoing monitoring.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently—always verify current requirements with Humana directly. For personalized assistance with appeals or coverage issues, consult with your healthcare provider or a qualified insurance advocate.

Sources & Further Reading

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