By Counterforce Health Team in Filsuvez (birch triterpenes topical gel) —

How to Get Filsuvez (Birch Triterpenes) Covered by Humana in Ohio: Complete Requirements Checklist

Answer Box: Getting Filsuvez Covered by Humana in Ohio

Filsuvez (birch triterpenes topical gel) requires prior authorization from Humana Medicare Advantage plans in Ohio. The fastest path to approval involves: (1) confirming your EB subtype diagnosis with genetic testing and ICD-10 code Q81.2 (dystrophic) or Q81.1/Q81.8 (junctional), (2) submitting a complete prior authorization request through Humana's provider portal with detailed wound care documentation, and (3) routing the prescription to CenterWell Specialty Pharmacy at 1-800-486-2668. If denied, Ohio residents have 65 days to appeal internally and 180 days for external review through the Ohio Department of Insurance.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Prevention Tips
  10. Appeals Process in Ohio
  11. Printable Requirements Checklist

Who Should Use This Checklist

This guide is designed for patients with epidermolysis bullosa (EB) and their healthcare providers seeking Humana coverage for Filsuvez in Ohio. You'll need this if:

  • You have dystrophic or junctional EB with partial-thickness wounds
  • You're enrolled in a Humana Medicare Advantage plan in Ohio
  • Your provider has prescribed Filsuvez for wound care
  • You've received a prior authorization denial and need to appeal

Expected outcome: With proper documentation, most medically necessary Filsuvez requests are approved within 7-30 days. Humana's PA denial rate is approximately 3.5%, among the lowest of major insurers.

Member & Plan Basics

Coverage Verification

Before starting, confirm these basics:

Requirement What to Check Where to Find It
Active Coverage Current enrollment status Humana member portal or ID card
Plan Type Medicare Advantage Part C/D Policy documents
Formulary Status Filsuvez tier placement Humana formulary search
Prior Authorization Required for all Filsuvez prescriptions PA search tool
Note: New Humana members actively using Filsuvez may receive a 90-day transition period without prior authorization to prevent care disruption.

Clinical Criteria Requirements

Primary Indication

Filsuvez is FDA-approved specifically for:

  • Wound care in junctional or dystrophic epidermolysis bullosa
  • Patients ≥6 months old
  • Partial-thickness wounds only

Diagnostic Confirmation Required

Your medical records must include:

Laboratory Evidence:

  • Immunofluorescence antigen mapping results
  • Genetic testing confirming EB subtype
  • Electron microscopy (if performed)

Clinical Documentation:

  • Confirmed diagnosis of dystrophic EB (ICD-10: Q81.2) or junctional EB (ICD-10: Q81.1 or Q81.8)
  • Current wound assessment with photographs
  • Previous wound care treatments attempted and outcomes
  • Contraindications to standard therapies (if applicable)
Clinician Corner: Medical necessity requires documentation showing conventional wound care has been insufficient and that Filsuvez is appropriate for the specific EB subtype and wound characteristics.

Coding & Billing Requirements

Essential Codes

Code Type Code Description
ICD-10 Q81.2 Dystrophic epidermolysis bullosa
ICD-10 Q81.1 Junctional epidermolysis bullosa, letalis
ICD-10 Q81.8 Other epidermolysis bullosa
HCPCS J3490 Unclassified drugs (temporary code)
NDC 10122-310-02 Filsuvez 25 mL tube (primary)
NDC 76431-310-01 Alternative NDC code

Billing Specifications

  • Supply: 25 mL tubes for single-use only
  • Application: 1 mm layer at each dressing change
  • Units: Report per tube dispensed
  • Modifiers: Include NDC code on all claims using J3490

Documentation Packet Essentials

Provider Note Elements

Your healthcare provider's documentation should include:

Patient History:

  • Date of EB diagnosis and confirming tests
  • Family history of EB (if applicable)
  • Previous hospitalizations or complications
  • Current wound status and location

Physical Examination:

  • Detailed wound assessment with measurements
  • Photographs (if available and consented)
  • Evidence of wound progression or healing challenges
  • Assessment of infection risk

Treatment History:

  • Previous wound care products tried
  • Outcomes of prior therapies
  • Reasons for discontinuation or failure
  • Current wound care regimen

Letter of Medical Necessity Components

Include these key elements:

  1. Patient identification and confirmed EB subtype
  2. Clinical rationale for Filsuvez specifically
  3. Previous treatment failures with standard wound care
  4. Expected outcomes and monitoring plan
  5. FDA label alignment showing appropriate use
  6. Duration of therapy needed

Required Attachments

  • Recent clinic notes (within 30 days)
  • Laboratory/genetic testing results confirming EB subtype
  • Wound care history documentation
  • Previous authorization denials (if resubmitting)
  • Prescription with specific dosing instructions

Submission Process

Step-by-Step Submission

  1. Verify Requirements: Use Humana's PA search tool to confirm current requirements
  2. Complete Documentation: Gather all required clinical information and attachments
  3. Submit Request:
  4. Track Status: Monitor through provider portal or call customer service

Common Submission Errors

  • Incomplete EB subtype confirmation
  • Missing wound care history
  • Incorrect ICD-10 coding
  • Insufficient clinical justification
Tip: Humana aims to process 95% of electronic prior authorization requests within one business day by 2026.

Specialty Pharmacy Routing

CenterWell Specialty Pharmacy

Filsuvez must be dispensed through Humana's specialty pharmacy network:

Prescription Submission:

  • E-prescribe: Electronic submission (preferred)
  • Fax: 1-877-405-7940
  • Phone: 1-800-486-2668

Care Coordination:

  • Available Monday-Friday, 8 AM-8 PM ET
  • Saturday, 8 AM-6 PM ET
  • Expedited shipping available
  • Financial assistance specialists on staff

Transfer Process

If currently using another pharmacy:

  1. Contact CenterWell at 1-800-486-2668
  2. Provide current pharmacy information
  3. Authorize prescription transfer
  4. Verify shipping address and preferences

After Submission: What to Expect

Timeline Expectations

Review Type Processing Time Next Steps
Standard PA 7-30 days Automatic notification
Expedited PA ≤72 hours Provider follow-up required
Peer-to-peer 1-3 business days Scheduled call with medical director

Status Monitoring

  • Confirmation numbers: Record all reference numbers
  • Portal checks: Monitor status weekly
  • Documentation: Keep copies of all submissions

When specialized platforms like Counterforce Health help streamline this process, they can identify denial patterns specific to your plan and craft targeted appeals that address Humana's exact coverage criteria for Filsuvez.

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Insufficient EB Subtype Documentation
  2. Missing Treatment History
    • Fix: Document all previous wound care attempts with outcomes
    • Source: Medical necessity standards
  3. Incorrect Pharmacy Routing
  4. Incomplete Clinical Justification
    • Fix: Explain why standard wound care is insufficient
    • Source: FDA labeling and clinical guidelines
  5. Missing Age Verification

Appeals Process in Ohio

Internal Appeals with Humana

If your initial request is denied:

Timeline: 65 days from denial date Method: Humana provider portal or member services Required: Additional clinical documentation addressing denial reasons

External Review in Ohio

For continued denials:

Eligibility: Must complete internal appeals first Timeline: 180 days from final internal denial Process: Contact Ohio Department of Insurance Phone: 1-800-686-1526

Review Entity: Independent Review Organization (IRO) with EB expertise Decision Timeline: 30 days standard, 72 hours expedited Binding: IRO decisions are final and binding on Humana

When to Escalate

Contact Ohio regulators if:

  • Humana fails to meet appeal deadlines
  • Required forms are not provided
  • Medical necessity criteria seem unreasonable

Printable Requirements Checklist

Before You Start

  • Active Humana Medicare Advantage coverage confirmed
  • EB subtype diagnosis confirmed with genetic testing
  • Current wound assessment completed
  • Previous wound care treatments documented

Clinical Documentation

  • ICD-10 code: Q81.2 (dystrophic) or Q81.1/Q81.8 (junctional)
  • Laboratory confirmation of EB subtype
  • Detailed wound care history
  • Medical necessity letter completed
  • Recent clinic notes (within 30 days)

Submission Requirements

  • Prior authorization request submitted via Humana portal
  • All required attachments included
  • Prescription routed to CenterWell Specialty Pharmacy
  • Confirmation numbers recorded
  • Follow-up schedule established

If Denied

  • Internal appeal filed within 65 days
  • Additional clinical evidence submitted
  • External review requested within 180 days (if needed)
  • Ohio Department of Insurance contacted (if applicable)

Counterforce Health specializes in transforming insurance denials into successful appeals by analyzing plan-specific coverage criteria and crafting evidence-backed rebuttals. Their platform helps patients and providers navigate complex prior authorization requirements for specialty medications like Filsuvez, turning coverage challenges into approved treatments.

Frequently Asked Questions

How long does Humana prior authorization take for Filsuvez in Ohio? Standard requests process within 7-30 days, with expedited reviews available within 72 hours for urgent clinical situations.

What if Filsuvez isn't on Humana's formulary? Submit a formulary exception request with medical necessity documentation showing why covered alternatives are inappropriate.

Can I request an expedited appeal in Ohio? Yes, expedited reviews are available when delays would seriously jeopardize your health. Contact Humana member services to request expedited processing.

Does step therapy apply to Filsuvez? Step therapy requirements vary by plan. Document previous wound care failures to support medical necessity.

What happens if my appeal is denied in Ohio? You can request external review through the Ohio Department of Insurance within 180 days of the final internal denial.

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 specific coverage requirements. Coverage policies may change; verify current requirements with Humana and Ohio regulators. For additional assistance with health insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

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