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

How to Get Evkeeza (Evinacumab-dgnb) Covered by Humana in Washington: Complete Timeline & Appeals Guide

Answer Box: Getting Evkeeza Covered by Humana in Washington

Evkeeza (evinacumab-dgnb) requires prior authorization from Humana with genetic confirmation of homozygous familial hypercholesterolemia (HoFH) and documented failure of standard lipid-lowering therapies. Standard review takes 30 days; expedited review 72 hours. If denied, you have 65 days to appeal internally, then can request external review through Washington's Independent Review Organization (IRO). Start today: Contact your prescriber to gather genetic testing results, prior therapy records, and current LDL-C labs for the PA submission.

Table of Contents

What Affects Approval Timeline

Several factors determine how quickly Humana processes your Evkeeza prior authorization in Washington:

Documentation completeness is the biggest factor. Humana processes complete electronic requests within one business day, while incomplete submissions can add 7-14 days for additional information requests.

Benefit type matters too. Medicare Advantage plans follow federal timelines (30 days standard, 72 hours expedited), while commercial plans may have different state-mandated timeframes in Washington.

Clinical complexity affects review time. HoFH cases requiring genetic confirmation and extensive prior therapy documentation typically need the full review period, especially if submitted to medical directors for case-by-case evaluation.

Tip: Electronic submissions through Humana's provider portal process faster than fax or phone requests. Your prescriber should use the online system whenever possible.

Pre-Submission Preparation (0-2 Days)

Before submitting your prior authorization, gather these essential documents:

Required Clinical Documentation

  • Genetic testing results confirming HoFH (pathogenic variants in LDLR, APOB, PCSK9, or LDLRAP1 genes)
  • Current LDL-C levels showing >400 mg/dL despite maximally tolerated therapy
  • Prior therapy records documenting failure/intolerance of:
    • At least two statins at maximum tolerated doses (≥3 months each)
    • Statin plus ezetimibe (≥8 weeks)
    • PCSK9 inhibitor (≥3 months)
  • Physical exam findings (tendon xanthomas, family history)
  • Treatment plan with monitoring schedule and target LDL-C goals

Administrative Information

  • Insurance card and member ID
  • Prescriber NPI and DEA numbers
  • ICD-10 code E78.01 (familial hypercholesterolemia)
  • Preferred infusion site details

Download Humana's PCSK9 and Select Lipotropics PA form to ensure you have all required fields completed.

Submission to Initial Review (1-5 Days)

How to Submit

Electronic submission (fastest): Your prescriber should use Humana's provider portal for quickest processing.

Alternative methods:

  • Fax: Check your specific plan's PA fax number (verify with current documentation)
  • Phone: Provider services line on your insurance card

What Reviewers Check First

Humana's initial review focuses on:

  1. Diagnosis confirmation - Is HoFH properly documented?
  2. FDA age requirements - Patient must be ≥5 years old
  3. Prior therapy documentation - Were standard treatments tried and failed?
  4. Prescriber qualifications - Is this from an appropriate specialist?

Counterforce Health specializes in helping patients navigate complex prior authorization requirements like those for Evkeeza. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address each payer's specific criteria.

Note: If any required documentation is missing, expect an additional information request that adds 3-7 business days to the timeline.

Decision Window & Outcomes

Standard Timeline

  • Standard review: 30 days for pre-service decisions
  • Expedited review: 72 hours if clinical urgency is documented
  • Electronic submissions: Often decided within 1 business day when complete

Possible Outcomes

Approval: You'll receive a written determination with:

  • Coverage effective dates
  • Approved quantity and frequency
  • Any special requirements (preferred infusion sites, monitoring)

Partial approval: May approve with restrictions like:

  • Step therapy requirements
  • Quantity limits
  • Site-of-care limitations

Denial: Written notice will include:

  • Specific denial reasons
  • Appeal rights and deadlines
  • Required documentation for reconsideration

If Denied: Appeals Process

Internal Appeals (First Level)

Timeline: You have 65 days from the denial notice to file an internal appeal.

Required documents:

  • Original denial letter
  • Additional clinical evidence addressing denial reasons
  • Prescriber's letter of medical necessity
  • Any new lab results or genetic testing

Processing time:

  • Standard: 30 days
  • Expedited: 72 hours (if delay could jeopardize health)

External Review (Second Level)

If Humana upholds the denial, Washington state provides robust external review rights through Independent Review Organizations (IROs).

Timeline: 180 days from final internal denial to request external review

Process:

  1. Submit request to Washington Office of the Insurance Commissioner or directly to Humana
  2. IRO assigned automatically from state registry
  3. Standard review: 30 days for IRO decision
  4. Expedited review: 72 hours for urgent cases

Contact Washington's Office of the Insurance Commissioner at 1-800-562-6900 for help with the external review process.

Important: IRO decisions are binding on Humana. If they overturn the denial, your insurer must provide coverage.

Renewal Cycles

Annual reauthorization required. Submit renewal requests 30-60 days before your current authorization expires to avoid treatment gaps.

Renewal Documentation

  • Updated LDL-C lab results
  • Current treatment response assessment
  • Confirmation of continued HoFH diagnosis
  • Documentation of ongoing maximally tolerated lipid-lowering therapy

New in 2025: Humana may implement additional step therapy requirements for renewals, so maintain thorough documentation of all therapy trials and outcomes.

Timeline Overview

Phase Timeline Key Actions
Preparation 0-2 days Gather documentation, complete PA forms
Submission 1-5 days Submit via provider portal or fax
Initial Review 1-30 days Humana reviews for completeness and criteria
Additional Info 3-7 days Respond to any documentation requests
Decision Same day-30 days Approval, denial, or partial approval
Internal Appeal 30-72 hours If denied, file within 65 days
External Review 30 days IRO decision if internal appeal fails

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
HoFH Diagnosis Genetic or clinical confirmation Genetic testing or LDL-C >400 mg/dL + family history
Age Requirement Patient ≥5 years old Date of birth verification
Prior Therapies Failed standard treatments Pharmacy records, clinical notes
Specialist Prescriber Lipidologist, cardiologist, or endocrinologist Prescriber credentials
Monitoring Plan Regular LDL-C tracking Treatment protocol with lab schedule

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Insufficient HoFH documentation Submit genetic testing results or detailed phenotypic criteria with family history
Inadequate prior therapy trials Provide pharmacy records showing ≥3 months of statin therapy, ezetimibe trial, and PCSK9 inhibitor attempt
Non-specialist prescriber Transfer care to lipidologist or obtain specialist consultation letter
Missing lab values Submit current and historical LDL-C levels showing persistent elevation despite therapy
Age requirement not met Verify patient is ≥5 years old per FDA labeling

FAQ

How long does Humana prior authorization take for Evkeeza in Washington? Standard review takes up to 30 days, but complete electronic submissions often receive decisions within 1 business day. Expedited review is available within 72 hours for urgent cases.

What if Evkeeza is non-formulary on my Humana plan? You can request a formulary exception with your prescriber's supporting statement explaining medical necessity. The same prior authorization requirements apply.

Can I request an expedited appeal in Washington? Yes, if waiting for a standard decision could seriously jeopardize your health. Your prescriber must document the clinical urgency in their supporting statement.

Does step therapy apply if I've tried treatments outside Washington? Yes, Humana accepts prior therapy documentation from any provider, regardless of location. Ensure you have complete pharmacy records and clinical notes.

What happens if my appeal is denied by the IRO? IRO decisions are typically final, but you can contact the Washington Office of the Insurance Commissioner for further guidance or consider legal consultation for cases meeting certain criteria.

How much will Evkeeza cost with Humana coverage? With Medicare Part D, the 2025 out-of-pocket cap is $2,000 annually. Commercial plans vary, but manufacturer copay assistance may be available to reduce costs.

From our advocates: We've seen HoFH patients successfully overturn initial denials by working closely with their lipid specialists to document the genetic basis of their condition and the systematic failure of standard therapies. The key is comprehensive documentation that tells the complete clinical story—not just meeting individual criteria in isolation.

When navigating complex prior authorization requirements, Counterforce Health helps patients and providers turn insurance denials into successful appeals by analyzing plan policies and creating evidence-backed rebuttals aligned to each payer's specific criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current coverage criteria and requirements. Coverage policies may change, and individual circumstances vary.

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