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

How to Get Evkeeza (evinacumab-dgnb) Covered by Humana in New Jersey: Forms, Appeals & Step Therapy Override

Answer Box: Fastest Path to Evkeeza Coverage

Evkeeza (evinacumab-dgnb) is a nonpreferred drug under Humana's Medicare Advantage Part B step therapy requirements. You must first try Repatha (PCSK9 inhibitor) unless contraindicated. To get coverage: 1) Submit prior authorization through Humana's provider portal with documentation of Repatha failure/intolerance, 2) If denied, file an internal appeal within 65 days, 3) Request expedited IHCAP external review through 1-800-MEDICARE for specialty drug denials. New Jersey's Independent Health Care Appeals Program provides binding external review at no cost to you.

Table of Contents

Plan Types & Coverage Rules

Humana offers several plan types in New Jersey, each with different rules for specialty medications like Evkeeza:

Medicare Advantage (Part C): Most common Humana plan type in New Jersey. Evkeeza falls under Part B coverage when administered in medical offices, requiring prior authorization and step therapy compliance.

Medicare Part D: Prescription drug coverage that may apply if Evkeeza is dispensed through specialty pharmacy for home administration (rare for this IV medication).

Commercial Plans: Individual and employer-sponsored plans follow similar PA requirements but may have different formulary tiers and appeals processes.

Note: Humana's Medicare Advantage denial rate is approximately 3.5% (2023), among the lowest of major insurers, but denials often involve formulary placement or documentation gaps.

Formulary Status & Tier Placement

Coverage at a Glance

Requirement What It Means Where to Find It Source
Formulary Status Nonpreferred drug, Part B coverage Humana formulary lookup 2025-2026 PDG
Step Therapy Must try Repatha first Part B step therapy list Humana Step Therapy Policy
Prior Authorization Required for all requests PA search tool PA Lists
HCPCS Code J1305 Medical billing FDA labeling

Evkeeza is classified as nonpreferred under Humana's 2025-2026 formularies, meaning higher cost-sharing and mandatory step therapy requirements apply.

Prior Authorization Requirements

All Evkeeza requests require prior authorization through Humana's system. The PA must demonstrate:

  1. Confirmed HoFH diagnosis with genetic testing or clinical criteria
  2. Prior therapy documentation showing Repatha trial/failure
  3. Medical necessity for this specific ANGPTL3 inhibitor
  4. Appropriate dosing (15 mg/kg every 4 weeks IV)

Required Documentation

Your prescriber must submit:

  • Complete medical history and physical exam
  • Laboratory results (LDL-C levels, genetic testing if available)
  • Documentation of prior lipid-lowering therapies and outcomes
  • Contraindications to preferred alternatives
  • Treatment goals and monitoring plan

Contact Humana Monday–Friday 8 a.m.–8 p.m. ET for PA status updates.

Step Therapy Override Process

Humana requires trying Repatha before covering Evkeeza, but exceptions apply for patients who:

  • Have a paid claim for Evkeeza in the past year
  • Are already stabilized on the medication
  • Have documented contraindications to Repatha
  • Experienced therapeutic failure or adverse effects with PCSK9 inhibitors

Step-by-Step Override Request

  1. Gather evidence of Repatha trial (minimum 3 months at maximum tolerated dose)
  2. Document outcomes - lack of efficacy or adverse effects
  3. Submit override request with prescriber's supporting statement
  4. Include clinical rationale for why Evkeeza is specifically needed
  5. Reference guidelines supporting ANGPTL3 inhibition for refractory HoFH
  6. Specify monitoring plan for infusion reactions and efficacy
  7. Track submission through provider portal or member services

Expected timeline: 7-30 days for standard requests, 24-72 hours for expedited reviews.

Specialty Pharmacy Network

Humana distributes Evkeeza through CenterWell Specialty Pharmacy, their owned specialty pharmacy network.

CenterWell Specialty Pharmacy Services:

  • Medication delivery coordination
  • Financial assistance program support
  • Clinical support and monitoring
  • Insurance verification and PA assistance

Contact Information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Hours: Monday–Friday 8 a.m.–11 p.m.; Saturday 8 a.m.–6:30 p.m. ET

The medication is typically shipped to your infusion center or specialty clinic for administration, as Evkeeza requires IV infusion every 4 weeks.

Cost-Share Dynamics

As a nonpreferred specialty medication, Evkeeza carries higher out-of-pocket costs:

Typical Cost Structure:

  • Deductible: May apply before coverage begins
  • Coinsurance: Often 20-40% for nonpreferred specialty drugs
  • Annual out-of-pocket maximum: Provides cost protection
Tip: Regeneron offers patient assistance programs that may help reduce cost-sharing. Contact CenterWell Specialty Pharmacy to explore available options.

Submission Process

For Providers

Submit PA requests through:

  • Availity Provider Portal: Primary submission method
  • Humana Provider Portal: Prior authorization section
  • Fax: 877-486-2621 (verify current number)
  • Phone: Provider services line for urgent requests

For Patients

If your doctor needs support:

Appeals Playbook for New Jersey

Internal Appeals (Level 1)

Timeline: File within 65 days of denial notice Decision: 30 days (pre-service) or 60 days (post-service) Submission: Humana member portal, mail, or Availity

Required elements:

  • Member details and plan information
  • Copy of denial notice
  • Prescriber's letter explaining medical necessity
  • Clinical records supporting HoFH diagnosis
  • Documentation of prior therapy failures

IHCAP External Review (New Jersey Fast-Track)

New Jersey's Independent Health Care Appeals Program offers binding external review for Medicare Advantage denials.

Eligibility: Automatic after Humana internal appeal denial Timeline: File within 65 days of internal denial Cost: Free to patients Decision: Up to 72 hours (expedited) or 30-60 days (standard)

How to Request:

  1. Call 1-800-MEDICARE with plan details and denial information
  2. Request expedited review citing risk from untreated HoFH
  3. Submit medical records and prescriber statement
  4. Track status through Medicare.gov/appeals

New Jersey Resources:

  • NJ SHIP: 1-800-792-8820 (free counseling)
  • IHCAP Hotline: 1-888-393-1062
  • NJ DOBI Consumer Hotline: 1-800-446-7467

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Step therapy not completed Submit Repatha trial documentation showing failure/intolerance
Diagnosis not established Provide genetic testing or phenotypic HoFH criteria documentation
Not medically necessary Include peer-reviewed evidence and guideline references
Alternative available Document contraindications or failures with PCSK9 inhibitors
Site of care issues Clarify infusion center capabilities and medical supervision

Clinician Corner: Medical Necessity Letter

Your prescriber's letter should address:

  • Problem: Severe, refractory hypercholesterolemia despite maximal therapy
  • Prior treatments: Specific statins, ezetimibe, PCSK9 inhibitors tried with doses and durations
  • Clinical rationale: Why ANGPTL3 inhibition is uniquely needed
  • Guideline support: Reference FDA approval for HoFH and relevant society recommendations
  • Monitoring plan: Infusion reaction management and efficacy assessment
From our advocates: We've seen successful appeals when prescribers include specific LDL-C levels before and after prior therapies, document genetic testing results when available, and clearly explain why the patient's HoFH is refractory to standard treatments. The key is painting a complete clinical picture that shows Evkeeza as the logical next step.

FAQ

How long does Humana prior authorization take in New Jersey? Standard PA decisions are made within 7-30 days. Expedited requests (when delay could cause serious harm) are processed within 24-72 hours.

What if Evkeeza is non-formulary on my plan? Submit a formulary exception request with your prescriber's supporting statement. Include documentation that all formulary alternatives would be less effective or cause adverse effects.

Can I request an expedited appeal for Evkeeza? Yes, if waiting for standard processing could seriously harm your health or ability to regain maximum function. Untreated HoFH with cardiovascular risk may qualify.

Does step therapy apply if I tried Repatha outside New Jersey? Yes, documented trials from any location count toward step therapy requirements. Ensure your new provider has complete records of prior treatments.

What happens if IHCAP overturns Humana's denial? The decision is binding. Humana must provide coverage and cannot appeal the external reviewer's determination.

Are there cost assistance programs for Evkeeza? Regeneron offers patient support programs. CenterWell Specialty Pharmacy can help identify and apply for available assistance based on your insurance and financial situation.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed rebuttals. The platform identifies specific denial reasons and creates point-by-point responses aligned to each plan's own rules, pulling appropriate citations and weaving them into appeals with required clinical facts and operational details.

For complex cases like Evkeeza approvals, having expert support can make the difference between approval and denial. Counterforce Health specializes in transforming coverage challenges into successful outcomes through systematic, evidence-based advocacy.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult your healthcare provider and insurance plan documents for specific guidance. For additional help with insurance appeals in New Jersey, contact the state's consumer assistance programs listed above.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.