By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea or Lucentis Covered by Humana in Washington: Prior Authorization Forms, Appeal Scripts, and Timeline Guide

Answer Box: Your Fastest Path to Coverage

Getting Eylea or Lucentis covered by Humana in Washington requires prior authorization with step therapy requirements. You'll typically need to try preferred alternatives like Avastin (bevacizumab) or Eylea HD first, unless contraindicated. Submit your PA request through Humana's provider portal with diagnosis codes, OCT/FA imaging, and clinical justification. Standard decisions take up to 14 days; expedited reviews complete within 72 hours if vision loss is imminent. If denied, you have 65 days to appeal, with automatic external review by an Independent Review Entity (IRE) available in Washington.

Start today: Verify your plan's formulary tier for Eylea/Lucentis and gather recent OCT imaging and visual acuity measurements.

Table of Contents

  1. Before You Start: Plan and Coverage Verification
  2. Gather Required Documentation
  3. Submit Your Prior Authorization Request
  4. Follow-Up and Timeline Expectations
  5. If You Need More Information
  6. Appeals Process for Denials
  7. Renewal and Re-Authorization
  8. Quick Reference Checklist
  9. Frequently Asked Questions

Before You Start: Plan and Coverage Verification

Confirm Your Humana Plan Type

First, verify whether you have Humana Medicare Advantage (Part C) or a commercial plan, as this affects your appeal rights and timelines. Check your member ID card or call Humana member services at 1-800-457-4708.

Check Formulary Status

Eylea and Lucentis are typically non-preferred on Humana's 2025 formulary, requiring step therapy through preferred alternatives:

  • Preferred first-line options: Avastin (bevacizumab), Eylea HD, Vabysmo (faricimab), Pavblu (ranibizumab biosimilar)
  • Non-preferred (higher copay): Standard Eylea, Lucentis

You can verify your specific plan's formulary at Humana's drug list portal.

Verify Network Status

Confirm your retina specialist is in-network with your Humana plan. Out-of-network providers may require additional authorization steps or result in higher out-of-pocket costs.

Gather Required Documentation

Essential Clinical Information

Your provider will need to submit these documents with your PA request:

Diagnostic Requirements:

  • Recent OCT (Optical Coherence Tomography) or fluorescein angiography results
  • Visual acuity measurements (within 30 days)
  • ICD-10 diagnosis codes (e.g., H35.32 for wet AMD, E11.311 for diabetic macular edema)

Treatment History:

  • Documentation of preferred drug trials and outcomes
  • Contraindications or intolerances to step therapy options
  • Previous anti-VEGF injection responses and frequency

Clinical Justification:

  • Medical necessity rationale for non-preferred drug
  • Treatment goals and monitoring plan
  • Provider's clinical assessment

Step Therapy Documentation

Since Humana requires step therapy, you'll need evidence that preferred alternatives are inappropriate. Acceptable reasons include:

  • Documented allergy or intolerance to bevacizumab or other preferred agents
  • Failure to respond after adequate trial (typically 3-6 months)
  • Medical contraindication supported by clinical literature
  • Current successful therapy (if you've been on Eylea/Lucentis within the past 365 days)

Submit Your Prior Authorization Request

Submission Methods

Online Portal (Recommended):

  • Humana provider portal via Availity
  • Upload all supporting documents digitally
  • Receive electronic confirmation and tracking number

Phone:

  • Provider services: 1-866-421-5663 (7 AM–7 PM CT)
  • Medicare PA line: 1-866-488-5995

Fax:

  • Standard PA requests: 502-508-9300
  • Include cover sheet with member ID and provider NPI

Required Forms

Download current PA forms from Humana's prior authorization resources. Forms are updated annually, so verify you're using the 2025 version.

Clean Request Packet Checklist

  • ✅ Completed PA form with all fields
  • ✅ Member insurance card copy
  • ✅ Recent OCT or FA imaging with interpretation
  • ✅ Visual acuity measurements
  • ✅ Treatment history and step therapy documentation
  • ✅ Clinical notes supporting medical necessity
  • ✅ Provider attestation letter
Tip: Submit all documents together to avoid delays. Incomplete requests often result in automatic denials that require appeals.

Follow-Up and Timeline Expectations

Standard Processing Times

Humana's Decision Timelines:

  • Standard PA: Up to 14 days
  • Expedited/Urgent: 72 hours (requires clinical justification for urgency)
  • Medicare Part D: 7 days standard

When to Follow Up

Call Humana if you haven't received a decision by:

  • Day 10 for standard requests
  • Day 2 for expedited requests

Sample Follow-Up Script

"Hi, I'm calling to check the status of a prior authorization request for [member name], member ID [number]. The PA reference number is [number]. Can you tell me the current status and expected decision date?"

Document all interactions with reference numbers and representative names.

If You Need More Information

Common Information Requests

Humana may request additional documentation for:

  • More detailed treatment history: Specific dates, dosages, and outcomes of previous therapies
  • Updated imaging: Recent OCT showing current disease activity
  • Peer-reviewed literature: Supporting off-label use or specific clinical scenarios
  • Specialist consultation notes: Additional expert opinions

Handling Medical Necessity Questions

If Humana questions medical necessity, your provider should submit:

  1. Clinical guidelines from professional societies (American Academy of Ophthalmology, American Society of Retina Specialists)
  2. FDA labeling for approved indications
  3. Peer-reviewed studies supporting the treatment approach
  4. Detailed clinical rationale explaining why alternatives are inadequate

Appeals Process for Denials

Washington State Appeal Rights

If Humana denies your request, you have strong appeal rights under Washington law:

Internal Appeals:

  • Deadline: 65 calendar days from denial notice
  • Timeline: 30 days for medical services, 7 days for prescription drugs
  • Expedited: 72 hours if health could be seriously jeopardized

External Review:

  • Automatic escalation to Independent Review Entity (IRE) for Medicare plans
  • State external review available through Washington's Office of the Insurance Commissioner
  • Timeline: 30 days standard, 72 hours expedited

How to File an Appeal

Step 1: Internal Appeal

  • Submit written appeal within 65 days
  • Include denial letter and additional supporting documentation
  • Request expedited review if clinically urgent

Step 2: External Review

Appeal Success Strategies

Strengthen your appeal with:

  • Additional clinical documentation addressing denial reasons
  • Peer-to-peer review request with medical director
  • Updated imaging showing disease progression
  • Literature supporting medical necessity
From our advocates: We've seen appeals succeed when providers submit detailed treatment timelines showing why step therapy alternatives failed or caused adverse effects. Include specific dates, dosages, and clinical outcomes to build a compelling case.

Renewal and Re-Authorization

When to Resubmit

Most anti-VEGF authorizations require renewal every 6-12 months. Calendar your renewal request 30-45 days before expiration to avoid treatment gaps.

Renewal Documentation

For continuing therapy, submit:

  • Current OCT imaging showing treatment response or ongoing need
  • Visual acuity trends demonstrating stability or improvement
  • Treatment adherence and injection frequency
  • Updated clinical assessment with treatment goals

Streamlined Reauthorization

If you've been on the same medication for over a year with good outcomes, Humana may approve continuation therapy more quickly with abbreviated documentation.

Quick Reference Checklist

Before Submitting PA:

  • Verify formulary tier and step therapy requirements
  • Gather OCT/FA imaging (within 30 days)
  • Document visual acuity measurements
  • Compile step therapy trial history
  • Complete PA form with all required fields

During Review:

  • Follow up if no response by day 10
  • Document all reference numbers
  • Prepare additional documentation if requested

If Denied:

  • File internal appeal within 65 days
  • Request expedited review if urgent
  • Gather additional supporting evidence
  • Consider peer-to-peer review

Frequently Asked Questions

How long does Humana prior authorization take in Washington? Standard PA decisions take up to 14 days, while expedited reviews are completed within 72 hours if clinical urgency is documented.

What if Eylea or Lucentis is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Humana must provide a decision within the same timeframes as standard PA requests.

Can I request an expedited appeal in Washington? Yes, if your provider certifies that waiting could seriously jeopardize your health or vision. Expedited appeals must be decided within 72 hours.

Does step therapy apply if I was successful on Eylea/Lucentis outside Washington? If you've been on the medication within the past 365 days with documented success, Humana may waive step therapy requirements for continuation.

What's the difference between Medicare and commercial plan appeals? Medicare plans have automatic external review through IRE, while commercial plans use Washington's state external review process through the Insurance Commissioner.

Who can help me navigate the appeal process? Washington's SHIBA program provides free Medicare counseling, and the Insurance Commissioner's office assists with commercial plan appeals.

How much will Eylea or Lucentis cost with Humana coverage? Costs vary by plan, but expect 20% coinsurance for Medicare Part B coverage. Commercial plans may have different copay structures based on formulary tier.

Can I get help with medication costs? Yes, manufacturer patient assistance programs are available. Regeneron offers support for Eylea, and Genentech provides assistance for Lucentis through their patient support programs.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed prior authorization requests and appeal letters. Our platform analyzes denial letters and plan policies to identify the specific approval criteria and drafts point-by-point rebuttals with the right clinical evidence and citations.

For complex cases involving anti-VEGF medications, having expert support can significantly improve your chances of approval and reduce the time spent on administrative tasks. Counterforce Health's automated system ensures your appeals meet all procedural requirements while incorporating the clinical evidence payers need to see.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeal processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance plan. Coverage policies and procedures may change. Always verify current requirements with your specific plan and consult with qualified professionals for medical and legal advice.

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