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

How to Get Filsuvez (Birch Triterpenes Topical Gel) Covered by Humana in Virginia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Filsuvez Covered by Humana in Virginia

Filsuvez (birch triterpenes topical gel) requires prior authorization from Humana for epidermolysis bullosa wound care. Submit your PA request through Humana's provider portal or call 855-223-9868. Include genetic testing confirming junctional or dystrophic EB, wound documentation, and failed standard care attempts. Standard decisions take 7-30 days; expedited reviews are available for urgent cases. If denied, Virginia offers external review through the State Corporation Commission Bureau of Insurance within 120 days.

First step today: Verify your plan type (Medicare Advantage vs. Medicaid) and confirm Filsuvez requires PA using Humana's PA search tool.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Virginia
  7. If More Information is Requested
  8. If Your Request is Denied
  9. Renewal and Re-authorization
  10. Virginia External Review Process
  11. Quick Reference Checklist
  12. Frequently Asked Questions

What This Guide Covers

This guide helps patients with epidermolysis bullosa (EB) and their healthcare providers navigate Humana's prior authorization process for Filsuvez in Virginia. Filsuvez received FDA approval in December 2024 for wound care in junctional or dystrophic EB patients aged 6 months and older.

Who this helps:

  • Patients with confirmed junctional or dystrophic EB
  • Caregivers managing the approval process
  • Healthcare providers submitting PA requests
  • Anyone facing a Humana denial who needs appeal guidance

At Counterforce Health, we help patients turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to craft point-by-point rebuttals aligned with each plan's specific requirements.

Before You Start: Verify Your Coverage

Confirm Your Plan Type

Humana offers different plan types in Virginia, each with distinct PA processes:

Plan Type Coverage PA Process Contact
Medicare Advantage Part C medical + Part D pharmacy Provider portal or 855-223-9868 Member services on ID card
Virginia Medicaid State Medicaid managed by Humana Availity Essentials or 855-223-9868 1-800-555-1998
Commercial/Employer Group health plans Standard PA process Plan-specific number

Check Formulary Status

Use Humana's PA search tool to confirm Filsuvez requires prior authorization. The medication typically falls under specialty tier coverage due to its high cost (~$27,631 per GoodRx estimates).

Note: Filsuvez prescriptions must be dispensed through CenterWell Specialty Pharmacy, Humana's specialty pharmacy network.

Gather Required Documentation

Essential Clinical Documentation

Diagnosis Confirmation:

  • Genetic testing results confirming EB subtype
  • ICD-10 codes: Q81.1 (junctional EB) or Q81.2 (dystrophic EB)
  • Recent clinic notes from dermatologist or EB specialist (≤30 days)

Wound Assessment:

  • Current wound photos and measurements
  • Wound duration (≥3 weeks for partial-thickness wounds)
  • Wound size documentation (typically 10-50 cm²)
  • Progression photos over 3-6 months if available

Prior Treatment History:

  • Documentation of standard wound care trials
  • Specific therapies attempted and outcomes
  • Reasons for discontinuation or failure
  • Any contraindications to alternative treatments

Required Forms and Prescriptions

  • Humana PA form (available through provider portal)
  • Complete prescription with NDC codes (10122-310-02 or 76431-310-01)
  • Letter of medical necessity from prescribing physician
  • Patient demographics and Humana member ID

Submit Your Prior Authorization Request

Submission Methods

Preferred Method - Electronic:

  • Humana Provider Portal
  • 95% of electronic submissions receive response within 1 business day
  • Real-time tracking available

Alternative Methods:

  • Phone: 855-223-9868 (M-F 8am-5pm CT, TTY 711)
  • Fax: 877-405-7940 (for specialty medications)
  • CenterWell Specialty: 1-800-486-2668 for pharmacy-specific PAs

Clean Request Packet Checklist

✓ Complete PA form with all required fields ✓ Genetic testing confirmation ✓ Current wound assessment with photos ✓ Prior therapy documentation ✓ Letter of medical necessity ✓ Valid prescription with NDC codes ✓ Patient consent forms if applicable

Tip: Submit all documentation at once to avoid delays. Incomplete requests are the most common reason for extended processing times.

Follow-Up and Tracking

When to Call

  • Day 3: Confirm receipt if submitted by fax or mail
  • Day 7: Check status for standard requests
  • Day 15: Follow up if no decision received
  • Day 25: Escalate if approaching 30-day limit

Sample Call Script

"Hi, I'm calling to check the status of a prior authorization request for Filsuvez for [patient name], member ID [number]. The request was submitted on [date] with reference number [if available]. Can you provide a status update and expected decision timeline?"

Document: Date, time, representative name, reference numbers, and next steps.

Typical Timelines in Virginia

Standard Processing Times

Request Type Timeline Notes
Standard PA 7-30 days Most common for Filsuvez
Expedited PA ≤72 hours Requires urgent medical necessity
Peer-to-Peer Review 1-3 days After initial review
Appeal Decision 30 days Internal appeal process

Factors That Speed Decisions

  • Complete documentation submitted initially
  • Electronic submission through provider portal
  • Clear medical necessity rationale
  • Specialist (dermatologist/EB center) prescription

Factors That Slow Decisions

  • Missing genetic testing results
  • Incomplete prior therapy documentation
  • Unclear wound measurements or photos
  • Submission during high-volume periods

If More Information is Requested

Common Information Requests

Medical Necessity Questions:

  • Additional clinical rationale for Filsuvez vs. alternatives
  • Specific wound characteristics requiring birch triterpenes
  • Expected treatment duration and monitoring plan

Documentation Requests:

  • More detailed prior therapy records
  • Additional wound progression photos
  • Specialist consultation notes
  • Updated lab values or imaging

Response Strategy

Respond promptly with requested information to avoid delays. Include:

  • Reference to original PA request number
  • Clear answers to specific questions asked
  • Supporting literature if clinical rationale questioned
  • Updated prescription if dosing questions arise

If Your Request is Denied

Common Denial Reasons and Fixes

Denial Reason How to Overturn
Insufficient medical necessity Submit detailed letter with FDA approval data, clinical guidelines, and patient-specific rationale
Missing EB subtype confirmation Provide genetic testing results with specific mutation identified
Alternative therapies not tried Document all standard wound care attempts with specific outcomes
Non-formulary status Request formulary exception with medical necessity documentation

Internal Appeal Process

  1. File within 60 days of denial notice
  2. Include: Original request, denial letter, additional supporting evidence
  3. Submit via: Same portal/method as original request
  4. Timeline: 30 days for standard appeal decision

Peer-to-Peer Review

Request a peer-to-peer review where your prescribing physician speaks directly with Humana's medical director. This can often resolve clinical questions quickly.

To request: Call the number on your denial letter or contact member services.

Virginia External Review Process

If Humana's internal appeals are exhausted, Virginia law provides external review through the State Corporation Commission Bureau of Insurance.

Eligibility and Timeline

  • File within: 120 days of final internal denial
  • Standard review: 45 days for decision
  • Expedited review: 72 hours if delay could jeopardize health
  • Cost: Free to patients

How to File

  1. Download Form 216-A from the Virginia SCC website
  2. Include: Denial letters, medical records, provider recommendations, plan documents
  3. Submit to: SCC Bureau of Insurance (contact via scc.virginia.gov)
  4. Track: Bureau assigns independent review organization within 1 business day
Virginia Advantage: The state allows expedited external review for urgent cases without completing all internal appeals first, reflecting Virginia's commitment to timely care access.

Quick Reference Checklist

Before Starting

□ Verify Humana plan type and coverage □ Confirm Filsuvez requires PA □ Identify prescribing specialist

Documentation Needed

□ Genetic testing confirming EB subtype □ Current wound assessment and photos □ Prior treatment history with outcomes □ Complete prescription with NDC codes □ Letter of medical necessity

Submission

□ Submit via provider portal (preferred) □ Include all documents in one packet □ Note reference numbers and submission date □ Schedule follow-up calls

If Denied

□ Review denial reason carefully □ Gather additional supporting evidence □ File internal appeal within 60 days □ Consider peer-to-peer review □ Know Virginia external review rights

Frequently Asked Questions

Q: How long does Humana PA take for Filsuvez in Virginia? A: Standard requests take 7-30 days. Electronic submissions through the provider portal typically receive responses within 1 business day for 95% of cases.

Q: What if Filsuvez is non-formulary on my plan? A: Request a formulary exception by documenting medical necessity and failure of formulary alternatives. Include FDA approval data and clinical guidelines supporting Filsuvez use.

Q: Can I request expedited review for urgent EB wounds? A: Yes. If your physician certifies that waiting could jeopardize your health, request expedited PA (≤72 hours) or expedited appeal review.

Q: Does step therapy apply if I've tried treatments outside Virginia? A: Document all prior therapies regardless of location. Include medical records showing specific treatments tried, duration, and reasons for discontinuation.

Q: What happens if CenterWell Specialty Pharmacy can't fill my prescription? A: Contact Humana member services immediately. They can authorize temporary fills at other specialty pharmacies while resolving network issues.

Q: How often do I need to renew Filsuvez authorization? A: Initial authorizations typically last 3-6 months. Submit renewal requests 30 days before expiration with progress notes and updated wound photos.

At Counterforce Health, we specialize in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to craft targeted, evidence-backed rebuttals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan directly for specific coverage determinations. For assistance with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at scc.virginia.gov.

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