By Counterforce Health Team in Epidiolex (cannabidiol) —

How to Get Epidiolex (Cannabidiol) Covered by Humana in Washington: Prior Authorization Guide and Appeal Process

Answer Box: Getting Epidiolex Covered by Humana in Washington

Epidiolex requires prior authorization from Humana for all FDA-approved seizure disorders (Lennox-Gastaut syndrome, Dravet syndrome, tuberous sclerosis complex). The fastest path to approval:

  1. Confirm diagnosis with ICD-10 code and specialist consultation
  2. Document failed antiseizure medications or contraindications
  3. Submit PA through CenterWell Specialty Pharmacy or Humana provider portal with complete clinical documentation

Timeline: 7 days for standard decisions, 72 hours for expedited appeals. If denied, you have 65 days to appeal and can request external review through Washington's Independent Review Organization process.

Table of Contents

Humana Plan Types and Network Requirements

Humana operates primarily Medicare Advantage and Part D plans in Washington, with some commercial coverage. Your plan type affects coverage:

Medicare Advantage Plans:

  • Require in-network providers for specialty medications
  • May need referrals to neurology specialists
  • Combined medical and prescription coverage

Medicare Part D Plans:

  • Prescription-only coverage
  • Work with any Medicare-accepting provider
  • Focus on formulary and pharmacy network requirements
Note: Epidiolex must be prescribed by or in consultation with a neurologist or physician specializing in seizure disorders for initial approval.

Epidiolex Formulary Status and Tier Placement

Current Status (2024-2025):

  • Tier 4 (Non-Preferred Brand) on most Humana formularies
  • Prior authorization required for all indications
  • Step therapy applies unless contraindications documented

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all indications Humana Drug Lists
Formulary Tier Tier 4 (Non-Preferred Brand) Plan-specific formulary
Step Therapy Must try preferred alternatives first PA criteria documentation
Age Requirement 1 year or older FDA labeling requirements
Specialty Pharmacy CenterWell preferred CenterWell Specialty

Preferred Alternatives (Step Therapy):

  • Clobazam (Onfi)
  • Valproic acid/valproate
  • Lamotrigine
  • Levetiracetam
  • Topiramate

Prior Authorization and Step Therapy Requirements

FDA-Approved Indications Requiring PA

Lennox-Gastaut Syndrome:

  • Patient ≥1 year old
  • Tried or currently receiving ≥1 appropriate antiseizure medication
  • Documented seizure history with LGS diagnosis

Dravet Syndrome:

  • Patient ≥1 year old
  • Tried or currently receiving ≥1 appropriate antiseizure medication
  • Genetic confirmation or clinical diagnosis of Dravet syndrome

Tuberous Sclerosis Complex:

  • Patient ≥1 year old
  • Seizures associated with TSC
  • Prior antiseizure medication trial documented

Step Therapy Bypass Criteria

You can bypass step therapy if you have:

  • Documented contraindication to preferred alternatives
  • Previous failure or intolerance to required medications
  • Medical necessity for Epidiolex specifically
  • Allergy or adverse reaction to formulary options

Specialty Pharmacy Network and Dispensing

Preferred Partners

CenterWell Specialty Pharmacy (Humana's preferred):

  • Fax: 1-877-405-7940
  • Mail order available
  • Integrated with Humana systems for faster processing

Alternative In-Network Options:

  • AcariaHealth
  • Accredo
  • Amber Pharmacy
Tip: Use the EPIDIOLEX Engage Hub to route prescriptions to the correct specialty pharmacy automatically.

Prescription Requirements

Your prescription must include:

  • Titration schedule with specific dosing instructions
  • Patient weight (dosing is weight-based)
  • ICD-10 diagnostic code for the seizure disorder
  • Brand name specification (Epidiolex)

Cost-Sharing and Financial Considerations

Tier 4 Placement Means:

  • Higher copayments or coinsurance than preferred brands
  • Potential deductible application
  • Cost varies by specific plan

Financial Assistance Options:

  • Jazz Pharmaceuticals Patient Support Program
  • Medicare Extra Help/Low-Income Subsidies
  • State pharmaceutical assistance programs
  • Copay assistance programs (eligibility restrictions may apply)

Submission Process and Required Documentation

Step-by-Step: Fastest Path to Approval

  1. Gather Clinical Documentation (Patient/Clinic)
    • Liver function tests (ALT, AST, bilirubin)
    • Seizure diary or documentation
    • Prior medication trial records
    • Timeline: Immediate
  2. Obtain Specialist Consultation (Patient)
    • Neurologist or epilepsy specialist evaluation
    • Confirmed diagnosis with ICD-10 code
    • Timeline: Varies by appointment availability
  3. Complete Prior Authorization Form (Prescriber)
    • Submit through Humana provider portal or fax
    • Include all required clinical documentation
    • Timeline: Same day submission possible
  4. Route to Specialty Pharmacy (Prescriber)
    • Send prescription to CenterWell or approved network pharmacy
    • Include titration schedule and patient weight
    • Timeline: Same day
  5. Humana Review Process (Automatic)
    • Standard review: 7 calendar days
    • Expedited review: 72 hours (if urgent)
    • Timeline: As specified above
  6. Patient Notification (Humana)
    • Approval/denial notice sent to patient and prescriber
    • If approved, specialty pharmacy contacts patient
    • Timeline: Within 24 hours of decision
  7. Medication Dispensing (Specialty Pharmacy)
    • Patient setup and education
    • First fill coordination
    • Timeline: 2-3 business days after approval

Clinician Corner: Medical Necessity Documentation

Essential Elements for Strong PA Submissions:

Clinical History:

  • Specific seizure syndrome diagnosis
  • Seizure frequency and severity
  • Impact on quality of life and development

Prior Treatment Documentation:

  • Names of medications tried
  • Dosages and duration of trials
  • Reasons for discontinuation (ineffective, intolerant, contraindicated)
  • Specific adverse effects experienced

Supporting Evidence:

  • EEG findings supporting diagnosis
  • Genetic testing results (for Dravet syndrome)
  • Imaging studies (for TSC)
  • Specialist consultation notes

Treatment Plan:

  • Target dose and titration schedule
  • Monitoring plan for liver function
  • Concurrent medications and drug interactions
  • Expected outcomes and goals

Common Approval Patterns

Strongest Applications Include:

  • Clear diagnosis from epilepsy specialist
  • Documented failure of ≥2 preferred antiseizure medications
  • Specific adverse effects or contraindications to alternatives
  • Recent liver function tests within normal limits
  • Weight-appropriate dosing calculations

Common Weaknesses Leading to Denial:

  • Incomplete medication trial documentation
  • Missing specialist consultation
  • Unclear diagnosis or ICD-10 coding
  • Excessive dose requests without justification
  • Missing liver function monitoring plan

Appeals Process in Washington

Internal Appeals (Humana)

Timeline: 65 days from denial notice to file appeal

Standard Appeal Process:

  • Submit online, mail, or fax
  • Include additional clinical documentation
  • Decision within 7 days for Part D denials

Expedited Appeals:

  • Available if delay could jeopardize health
  • Decision within 72 hours
  • Prescriber can request on patient's behalf

External Review (Washington State)

If Humana denies your internal appeal, Washington residents can request Independent Review Organization (IRO) review:

Process:

Timeline:

  • Standard external review: 30 days
  • Expedited external review: 72 hours for urgent cases

Outcome: IRO decision is binding on Humana if favorable.

When to Contact Washington OIC

  • Humana fails to meet appeal timelines
  • Procedural violations during review process
  • Need assistance with appeal submission
  • Complaint about coverage determination process

Contact the Consumer Advocacy line at 1-800-562-6900 for guidance and template appeal letters.

Where to Verify Current Information

Official Sources:

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific denial basis, then drafts point-by-point rebuttals aligned to the plan's own rules using the right clinical evidence and procedural requirements.

FAQ

How long does Humana prior authorization take for Epidiolex in Washington? Standard PA decisions take 7 calendar days. Expedited requests are processed within 72 hours if medical urgency is documented.

What if Epidiolex isn't on my Humana formulary? Request a formulary exception through the same PA process. Include medical necessity documentation showing why covered alternatives aren't appropriate.

Can I get a temporary supply while PA is pending? Yes, Humana provides up to 30-day transition supplies for new members or formulary changes during the first 90 days of enrollment.

Does step therapy apply if I failed medications outside Washington? Yes, document all prior medication trials regardless of where they occurred. Out-of-state medical records are acceptable for step therapy bypass.

What's the fastest way to reach Humana about Epidiolex coverage? Call the number on your member ID card and ask for "pharmacy prior authorization" or "specialty pharmacy" department.

Can my doctor request a peer-to-peer review? Yes, prescribers can request to speak directly with Humana's medical director if the initial PA is denied. This often resolves complex cases quickly.

What if I can't afford the Tier 4 copay? Look into Jazz Pharmaceuticals' patient assistance program, Medicare Extra Help, or request a tier exception to move Epidiolex to a lower-cost tier.

How do I file an external review in Washington? Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 within 180 days of your final internal appeal denial.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently—always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with Counterforce Health or contacting the Washington Office of Insurance Commissioner's consumer advocacy services.

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