By Counterforce Health Team in Evkeeza (evinacumab-dgnb) —

How to Get Evkeeza (Evinacumab) Covered by Humana in Texas: Complete Prior Authorization Guide

Answer Box: Getting Evkeeza Covered by Humana in Texas

To get Evkeeza (evinacumab-dgnb) covered by Humana in Texas, you'll need prior authorization with documented homozygous familial hypercholesterolemia (HoFH) diagnosis and proof you've tried maximally tolerated background therapy. Start by having your doctor submit a PA request through Humana's provider portal with genetic testing results, recent LDL-C levels >400 mg/dL, and documentation of failed statin/ezetimibe/PCSK9 inhibitor trials. If denied, you have 65 days to file an internal appeal, then can request Texas external review through an Independent Review Organization (IRO) if still denied.

Table of Contents

Humana's Coverage Criteria for Evkeeza

Humana requires prior authorization for Evkeeza (evinacumab-dgnb) across all Medicare Advantage plans in Texas as of 2024. The drug remains on their high-cost specialty medication list despite recent reductions in PA requirements for other services.

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Required for all plans Complete PA form Humana PA Portal
HoFH Diagnosis Genetic confirmation preferred LDL-C >400 mg/dL untreated, genetic testing EAS Guidelines
Background Therapy Maximally tolerated regimen Statin + ezetimibe ± PCSK9i trials FDA Label
Age Requirement 5+ years old Birth certificate/medical record FDA Label
Specialty Pharmacy Designated network only Prescription routing Humana Formulary

Plan Types and Application

Humana's Evkeeza coverage criteria apply uniformly across:

  • Medicare Advantage (Part C) plans
  • Medicare Part D prescription drug plans
  • Some commercial employer plans (verify with specific policy)

The drug is typically classified as a Tier 5 specialty medication with quantity limits of one 15 mg/kg dose every 4 weeks.

Step-by-Step: Fastest Path to Approval

1. Confirm HoFH Diagnosis (Patient/Clinician)

Gather genetic testing results showing pathogenic mutations in LDLR, ApoB, PCSK9, or LDLRAP1 genes. If genetic testing unavailable, document untreated LDL-C levels >400 mg/dL with family history of familial hypercholesterolemia.

Timeline: Immediate if available; 2-4 weeks if testing needed
Submit to: Keep for PA documentation

2. Document Background Therapy Trials (Clinician)

Compile records showing trials of:

  • High-intensity statin (unless contraindicated)
  • Ezetimibe
  • PCSK9 inhibitor (evolocumab or alirocumab)
  • LDL apheresis consideration (if available)

Include specific medications, doses, duration, and reasons for discontinuation (lack of efficacy, intolerance, contraindications).

Timeline: Review past 6-12 months of treatment history
Submit to: Include in PA request

3. Submit Prior Authorization (Clinician)

Complete Humana's PA request through their electronic portal or call 1-800-555-2546 (CLIN) for provider assistance.

Timeline: 1 business day for complete electronic submissions
Expected response: Within 30 days (standard) or 72 hours (expedited)

4. Monitor and Follow Up (Patient/Clinician)

Track PA status through Humana's provider portal. If additional information requested, submit promptly to avoid delays.

Timeline: Check every 2-3 business days
Contact: Provider services line for status updates

Medical Necessity Documentation Requirements

Clinician Corner: Essential Documentation

Your medical necessity letter should include these components to meet Humana's review criteria:

Patient Identification:

  • Full name, Humana member ID, date of birth
  • Prescribing physician name and NPI

Clinical Justification:

  • HoFH diagnosis with genetic testing results or clinical criteria
  • Current LDL-C levels (within 90 days)
  • Cardiovascular risk assessment
  • Treatment goals (target LDL-C reduction)

Prior Therapy Documentation:

  • Complete medication trial history with dates
  • Specific reasons for discontinuation
  • Current background therapy regimen
  • Contraindications to standard therapies (if applicable)

Supporting Evidence:

  • FDA labeling for HoFH indication
  • Relevant clinical guidelines (EAS 2023 consensus)
  • Peer-reviewed studies supporting evinacumab efficacy
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements.

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
"Insufficient HoFH documentation" Submit genetic testing or detailed clinical criteria Lab results showing LDL-C >400 mg/dL, family history, physical findings
"Background therapy not maximized" Document all prior trials and contraindications Medication history with specific drugs, doses, durations, discontinuation reasons
"Not FDA-approved indication" Cite FDA labeling for HoFH FDA prescribing information
"Quantity/frequency exceeded" Confirm weight-based dosing calculation Patient weight, prescribed dose (15 mg/kg q4 weeks), administration schedule
"Non-preferred specialty pharmacy" Route through Humana network pharmacy Contact Humana to identify preferred specialty pharmacy options

Appeals Process in Texas

If your initial PA request is denied, Texas law provides strong appeal rights for Medicare Advantage members.

Internal Appeal (Level 1)

  • Deadline: 65 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • How to file: Online through Humana member portal, phone (1-800-HUMANA), or written request
  • Required: Denial letter, additional medical documentation, prescriber support letter

Expedited Appeals

Request expedited review if waiting for standard appeal timeline would jeopardize your health. Your physician must support the expedited request with documentation that delay could cause serious harm.

Eligibility: Services not yet received (not reimbursement requests)
Timeline: 72 hours for Part C/Part B drugs
Documentation: Physician letter stating medical urgency

External Review (Texas IRO)

If Humana's internal appeal is denied, you can request review by an Independent Review Organization (IRO) through the Texas Department of Insurance.

  • Deadline: 4 months from final internal denial
  • Timeline: 20 days standard, 5 days for urgent cases
  • Cost: Free (insurer pays IRO fees)
  • Binding: IRO decision is final and enforceable
Note: ERISA self-funded employer plans follow federal appeal rules, not Texas IRO process. Verify your plan type before pursuing external review.

Cost Savings and Support Programs

Manufacturer Assistance

Regeneron offers the MYEVKEEZA support program with:

  • Copay assistance up to $12,000 annually for commercially insured patients
  • Prior authorization support and appeal templates
  • Nurse case management for treatment coordination

Contact: 1-833-EVKEEZA (1-833-385-3392)

Specialty Pharmacy Benefits

Once approved, Evkeeza must be obtained through Humana's designated specialty pharmacy network, typically Express Scripts or Accredo. These pharmacies provide:

  • Coordination with infusion centers
  • Insurance benefits verification
  • Patient education and support
  • Adherence monitoring

When to Escalate: Texas External Review

Consider escalating to Texas external review if:

  • Humana's internal appeal is denied despite strong clinical evidence
  • The denial appears to contradict FDA labeling or established clinical guidelines
  • Delay in treatment could cause irreversible harm

Texas Resources for Help

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel (OPIC): 1-877-611-6742
  • Texas SHIP (Medicare counseling): Free assistance navigating Medicare appeals
  • Disability Rights Texas: Advocacy for patients with rare diseases

The platform developed by Counterforce Health can be particularly valuable at this stage, as it analyzes payer-specific workflows and produces letters that meet procedural requirements while tracking deadlines and required documentation.

FAQ

How long does Humana prior authorization take for Evkeeza in Texas?
Standard PA requests receive decisions within 30 days, but complete electronic submissions through Humana's provider portal are typically processed within 1 business day. Expedited requests must be decided within 72 hours.

What if Evkeeza is non-formulary on my Humana plan?
Humana supports formulary exceptions based on medical necessity. Submit a formulary exception request with documentation that Evkeeza is medically necessary and preferred alternatives are inappropriate or ineffective.

Can I request an expedited appeal if my PA is denied?
Yes, if waiting for standard appeal timeline (30 days) would jeopardize your health. Your physician must provide written support that delay could cause serious harm.

Does step therapy apply if I've tried similar medications outside Texas?
Yes, prior therapy trials from other states count toward step therapy requirements. Provide complete documentation of all previous treatments regardless of where they were prescribed.

What happens if the Texas IRO overturns Humana's denial?
The IRO decision is binding. Humana must provide coverage for Evkeeza according to the IRO's determination and cannot appeal the decision.

How much does Evkeeza cost without insurance?
The average wholesale acquisition cost is approximately $450,000 per year based on weight-based dosing (15 mg/kg every 4 weeks). This makes prior authorization approval critical for patient access.

Can I use GoodRx or other discount programs for Evkeeza?
Traditional discount programs don't apply to specialty biologics like Evkeeza. Focus on insurance coverage through PA approval and manufacturer assistance programs.

What if I'm switching from another insurance plan to Humana?
You may need to restart the PA process with Humana even if previously approved by another insurer. Gather all previous documentation to expedite the new PA request.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies may change, and individual circumstances vary. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions.

Sources & Further Reading

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