By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (Etanercept) Covered by Humana in Pennsylvania: Prior Authorization, Appeals & Medical Necessity Guide

Answer Box: Getting Enbrel Covered by Humana in Pennsylvania

Humana requires prior authorization for Enbrel (etanercept) in Pennsylvania, with step therapy protocols favoring biosimilars first. To get coverage: (1) Have your rheumatologist/dermatologist submit a prior authorization request with complete medical necessity documentation, including TB screening and failed therapy history, (2) If denied, file an internal appeal within 65 days using Humana's redetermination forms, (3) For Medicare Advantage denials, follow federal appeals process—Pennsylvania's new external review program doesn't cover Medicare plans.

Table of Contents

Humana's Coverage Policy Overview

Enbrel (etanercept) is classified as a Tier 5 specialty medication on Humana formularies, requiring strict utilization management. Coverage applies across Humana's plan types in Pennsylvania:

  • Medicare Advantage plans: Subject to CMS regulations with federal appeal rights
  • Medicare Part D: Formulary exceptions available for non-covered presentations
  • Commercial plans (where offered): State-regulated with access to Pennsylvania's external review

Key Coverage Parameters

Requirement Details Source
Prior Authorization Required for all presentations Humana PA Lists
Formulary Tier Tier 5 (Specialty) Humana Drug Lists
Quantity Limits 8 syringes/autoinjectors per 28 days Humana Formulary Guide
Specialty Pharmacy Required (CenterWell or approved network) Humana Provider Resources
Prescriber Requirements Rheumatologist or dermatologist preferred Coverage Criteria

Medical Necessity Requirements

Humana's medical necessity criteria for Enbrel center on FDA-approved indications and evidence-based treatment protocols. Your prescriber must document:

Primary Requirements

  • Confirmed diagnosis with appropriate ICD-10 codes for:
    • Rheumatoid arthritis (moderately to severely active)
    • Psoriatic arthritis
    • Ankylosing spondylitis
    • Plaque psoriasis (moderate to severe)
    • Polyarticular juvenile idiopathic arthritis
  • Disease activity documentation using validated measures:
    • DAS28 scores for rheumatoid arthritis
    • PASI scores for psoriasis
    • BASDAI for ankylosing spondylitis
  • Safety screening results (within 6 months):
    • Negative tuberculosis testing (PPD, IGRA, or chest X-ray)
    • Hepatitis B screening
    • Complete blood count and liver function tests

Clinical Documentation Standards

Your medical records must demonstrate:

  1. Inadequate response to conventional DMARDs (typically methotrexate) for at least 3 months
  2. Contraindications or intolerance to preferred biosimilars if step therapy applies
  3. Treatment goals and expected outcomes
  4. Monitoring plan for safety and efficacy
Clinician Corner: Medical Necessity Letter Essentials

Include these elements in your prior authorization submission:Patient's specific diagnosis with ICD-10 codesObjective disease activity scores (DAS28, PASI, etc.)Detailed history of prior DMARD trials with dates, dosages, and outcomesDocumentation of TB/hepatitis B screening within 6 monthsClinical rationale for Enbrel over biosimilar alternativesReference to FDA prescribing information and relevant treatment guidelines

Step Therapy & Exception Pathways

Humana typically requires biosimilar step therapy before approving brand-name Enbrel. Preferred alternatives include:

  • Erelzi (etanercept-szzs)
  • Eticovo (etanercept-ykro)

Medical Exception Criteria

You can bypass step therapy if you document:

  • Contraindications to biosimilar components
  • Previous intolerance to biosimilars with specific adverse events
  • Clinical urgency requiring immediate brand-name therapy
  • Formulary biosimilar unavailability at your specialty pharmacy

Exception Documentation

Submit detailed records showing:

  1. Specific adverse reactions to biosimilars (dates, symptoms, severity)
  2. Contraindication rationale with clinical evidence
  3. Prescriber attestation of medical necessity for brand-name Enbrel

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic)
  2. Complete Safety Screening (Patient)
    • Obtain TB testing (PPD, IGRA, or chest X-ray) within 6 months
    • Complete hepatitis B panel and baseline labs
    • Timeline: 1-2 weeks for results
  3. Gather Documentation (Clinic)
    • Medical records showing diagnosis and disease activity
    • Prior therapy history with specific outcomes
    • Current lab results and screening reports
    • Timeline: 2-3 days for record compilation
  4. Submit Prior Authorization (Prescriber)
  5. Await Decision (Patient/Clinic)
    • Standard review: 72 hours for coverage determination
    • Expedited review: 24-72 hours if medically urgent
    • Timeline: 1-3 business days
  6. Coordinate Specialty Pharmacy (Patient)
    • Enroll with CenterWell or approved network pharmacy
    • Schedule delivery and storage preparation
    • Timeline: 3-5 days for first shipment
  7. Monitor and Renew (Patient/Clinic)
    • Track therapy response and side effects
    • Submit renewal PA annually or as required
    • Timeline: Ongoing monitoring

Appeals Process in Pennsylvania

Internal Appeals (Humana)

If your initial PA is denied, you have 65 days from the denial notice to file an internal appeal.

Required Documents:

  • Completed Humana redetermination form
  • Additional medical evidence addressing denial reasons
  • Prescriber letter supporting medical necessity

Timeline:

  • Standard appeals: 7 days for Part D drugs, 30 days for Part C services
  • Expedited appeals: 72 hours if health is at risk

Pennsylvania-Specific Rights

Important: Pennsylvania's new external review program does not apply to Medicare Advantage or Part D plans. These follow federal Medicare appeals processes only.

For commercial Humana plans, Pennsylvania's Independent External Review Program offers a powerful appeal option after exhausting internal appeals:

  • Success rate: Approximately 50% of denials overturned in 2024
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: No fee to consumers
  • Deadline: 4 months after final internal denial

Submit requests through the Pennsylvania Insurance Department.

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to craft targeted, evidence-backed rebuttals. Our platform identifies the specific denial basis and drafts point-by-point responses aligned to each plan's own coverage rules.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Step therapy not completed" Document biosimilar trial/failure or contraindication Pharmacy records, adverse event notes, allergy history
"Not medically necessary" Strengthen clinical justification with guidelines Disease activity scores, treatment history, outcome measures
"Experimental/investigational" Cite FDA approval and compendia FDA label, NCCN guidelines, peer-reviewed studies
"Quantity exceeded" Justify dosing with clinical evidence Weight-based calculations, FDA dosing guidelines, specialist notes
"Missing documentation" Submit complete clinical package All screening results, prior therapy records, specialist consultation

Sample Appeal Language

"Patient has moderately severe rheumatoid arthritis (ICD-10: M05.79) with DAS28 score of 5.2 despite 4 months of methotrexate 20mg weekly. Biosimilar etanercept (Erelzi) was discontinued after 6 weeks due to injection site reactions requiring emergency care on [date]. Brand-name Enbrel is medically necessary per ACR guidelines for anti-TNF therapy in methotrexate-inadequate responders."

Cost Considerations & Patient Support

Out-of-Pocket Costs

  • Humana Medicare Part D: Up to $2,000 annual out-of-pocket maximum in 2025
  • Specialty tier copay: Typically 25-33% coinsurance until catastrophic coverage
  • Monthly costs: Can range from $500-2,000+ depending on plan phase

Financial Assistance Options

  • Enbrel Support: Amgen SupportPlus copay assistance (commercial plans only)
  • Patient foundations: Chronic Disease Fund, HealthWell Foundation
  • State programs: Pennsylvania CHIP, Medicaid expansion coverage
  • Manufacturer patient assistance: Income-based free drug programs

When to Escalate

Contact these resources if standard appeals fail:

Pennsylvania Insurance Department

  • Consumer Services: For commercial plan issues only
  • Phone: (verify current number at pa.gov)
  • Online: Request external review

Federal Resources (Medicare plans)

  • Medicare.gov: 1-800-MEDICARE for Part D appeals guidance
  • State Health Insurance Assistance Program (SHIP): Free local counseling
  • Pennsylvania Health Law Project: Free help for low-income patients
  • National MS Society: Advocacy for specialty drug access

For complex denials involving multiple coverage issues, Counterforce Health provides comprehensive appeal support by analyzing your specific situation and crafting evidence-based responses that address each payer's unique requirements.

From Our Advocates

"We've seen Humana approvals increase significantly when prescribers include specific disease activity scores and clearly document why biosimilars aren't appropriate. One patient's appeal succeeded after we helped structure the clinical narrative around ACR treatment guidelines and included detailed pharmacy records showing biosimilar intolerance. The key is addressing the exact denial reason with objective clinical evidence."

FAQ

How long does Humana prior authorization take for Enbrel in Pennsylvania? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited reviews (when health is at risk) are decided within 24-72 hours.

What if Enbrel isn't on my Humana formulary? Request a formulary exception through your prescriber. Include detailed medical justification for why formulary alternatives aren't clinically appropriate. Appeals follow the same timeline as PA denials.

Can I get expedited appeals in Pennsylvania? Yes, for both Humana internal appeals and Pennsylvania external review (commercial plans only). Your prescriber must document that waiting for standard review could seriously harm your health.

Does step therapy apply if I've used Enbrel successfully in another state? Previous successful therapy can support medical necessity, but you'll still need to document why biosimilars aren't appropriate. Include your treatment history and outcomes data.

What happens if I pay out-of-pocket during appeals? If your appeal succeeds, Humana must provide retroactive coverage and reimburse approved expenses. Keep all receipts and pharmacy documentation.

How do I find Pennsylvania-specific appeal forms? Medicare plans use federal forms available at humana.com. Commercial plans may use Pennsylvania external review forms at pa.gov.

Can my doctor request a peer-to-peer review? Yes, prescribers can request to speak directly with Humana's medical director. This often helps resolve denials based on clinical nuances not captured in written documentation.

What's the difference between Medicare and commercial plan appeals in Pennsylvania? Medicare plans follow federal appeals processes with multiple levels ending in administrative law judge review. Commercial plans can access Pennsylvania's external review program, which has shown approximately 50% success rates in overturning denials.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage policies vary by plan and may change. Always verify current requirements with your specific Humana plan and consult your healthcare provider for medical decisions. For personalized assistance with appeals and coverage determinations, consider consulting with advocacy organizations or services like Counterforce Health.

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