By Counterforce Health Team in Firazyr (icatibant injection) —

How to Get Firazyr (icatibant) Covered by Humana in Michigan: Prior Authorization Forms, Appeals, and Coding Requirements

Answer Box: Getting Firazyr Covered by Humana in Michigan

Firazyr (icatibant) requires prior authorization from Humana for hereditary angioedema (HAE) treatment. Your fastest path: Have your HAE specialist submit a PA request through Humana's provider portal with HAE diagnosis (ICD-10: D84.1), attack history, and self-administration training documentation. If denied, you have 65 days to appeal internally, then 127 days for Michigan's external review through DIFS. Start today: Call your prescriber to initiate the PA process and confirm they have your complete HAE documentation ready.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Firazyr (icatibant) coverage through Humana depends on whether your plan processes it as a medical or pharmacy benefit. Most Humana Medicare plans exclude Firazyr from Part B coverage because it's on Medicare's Self-Administered Drug (SAD) exclusion list.

Coverage Pathways

Medicare Part D/Commercial Plans: Firazyr is typically covered as a specialty pharmacy benefit requiring prior authorization. The medication is placed on the highest formulary tier with significant cost-sharing.

Medicare Part B: Generally excluded due to self-administration designation, though some exceptions may apply if administered in a clinical setting incident to physician services.

Note: Counterforce Health helps patients navigate these complex coverage pathways by analyzing denial letters and crafting targeted appeals based on your specific plan's policies.

ICD-10 and Documentation Requirements

Primary Diagnosis Code

ICD-10: D84.1 ("Defects in the complement system") specifically covers hereditary angioedema for insurance billing and prior authorization purposes.

Required Clinical Documentation

Your prescriber must include:

  • Laboratory confirmation: Low C4 levels and C1-esterase inhibitor (C1-INH) deficiency studies
  • Attack history: Frequency, severity, and locations of angioedema episodes
  • Family history: If available, genetic confirmation of HAE
  • Prior treatments: Documentation of therapies tried and their outcomes
  • Emergency department visits: Records of HAE-related acute care

Supporting Test Codes

  • CPT 86160: C4 complement level
  • CPT 86161: C1-esterase inhibitor functional assay

HCPCS/J-Code and NDC Requirements

Billing Codes

  • HCPCS J-Code: J1744 ("Injection, icatibant, 1 mg")
  • Units: Bill 30 units per 30 mg syringe (1 unit = 1 mg)
  • Maximum dosing: Up to 3 doses (90 mg total) per 24-hour period

NDC Requirements

Include the specific 11-digit NDC for the Firazyr product dispensed. NDCs vary by manufacturer and packaging, so verify with your pharmacy before billing.

Modifiers and Place of Service

  • Modifier JB: Use if required by your local Medicare contractor for subcutaneous administration
  • Place of Service 12: Home administration
  • Place of Service 11: Office-based administration

Clean Prior Authorization Request Anatomy

Essential Elements for Humana PA

Component Requirement Documentation
Diagnosis HAE confirmed ICD-10 D84.1 + lab results
Prescriber HAE specialist preferred Allergist/immunologist credentials
Training Self-administration competency Clinic notes with training date
Medical necessity Attack frequency/severity ER visits, prior therapy failures
Dosing Per FDA label 30 mg SC, max 3 doses/24h

Submission Methods

  • Online: Humana Provider Portal (fastest processing)
  • Fax: 800-594-5309 (verify current number)
  • Phone: 866-488-5995 for urgent requests

Common Coding Pitfalls to Avoid

Unit Conversion Errors

Mistake: Billing 1 unit for a 30 mg syringe Correction: Bill 30 units (1 unit = 1 mg per J1744 definition)

Missing NDC Information

Mistake: Submitting claims without the 11-digit NDC Correction: Always include the specific NDC for the dispensed product

Wrong Diagnosis Codes

Mistake: Using generic angioedema codes (T78.3) Correction: Use HAE-specific code D84.1 with complement deficiency documentation

Incomplete Training Documentation

Mistake: No evidence of self-administration training Correction: Include clinic notes with training date, trainer name, and patient competency confirmation

Humana Verification Process

Pre-Submission Verification

  1. Check formulary status: Use Humana's drug lookup tool to confirm current tier placement
  2. Verify PA requirements: Review current prior authorization lists for Firazyr
  3. Confirm submission method: Check provider portal for electronic PA capability

Benefits Investigation

Request your specialty pharmacy perform a benefits investigation to determine:

  • Formulary tier and cost-sharing
  • Quantity limits per fill
  • Required step therapy protocols
  • Preferred alternative medications

Pre-Submission Audit Checklist

Before submitting your Firazyr PA to Humana:

  • ICD-10 D84.1 included with supporting lab results
  • HCPCS J1744 with correct unit calculation (30 units per syringe)
  • 11-digit NDC for specific product
  • HAE specialist as prescriber (allergist/immunologist preferred)
  • Self-administration training documented in clinical notes
  • Attack history with frequency and severity details
  • Prior therapy failures documented with dates and outcomes
  • Emergency care records for HAE attacks included
  • Dosing rationale aligned with FDA labeling
  • Contact information for prescriber peer-to-peer review

Appeals Process in Michigan

Internal Appeal (First Level)

Timeline: 65 days from denial date Process: Submit appeal through Humana member portal or by mail Required: Original denial letter, clinical documentation, prescriber letter

External Review (Second Level)

Michigan offers robust external review rights through the Department of Insurance and Financial Services (DIFS).

Timeline: 127 days after final internal denial Process: Submit External Review Request to DIFS Expedited: 72 hours for urgent medical needs with physician attestation

From our advocates: We've seen Michigan external reviews succeed when patients include comprehensive attack logs showing emergency department visits and failed alternative therapies. The key is demonstrating that Firazyr isn't just preferred—it's medically necessary based on your specific HAE pattern.

Michigan External Review Contact

Phone: 877-999-6442 (toll-free DIFS consumer hotline) Online: Michigan DIFS External Review Portal

Cost Assistance Options

Manufacturer Support

Takeda Patient Assistance: Income-based programs for eligible patients Eligibility: Varies by insurance type (Medicare patients typically excluded from copay cards)

Foundation Programs

  • Patient Access Network Foundation: HAE-specific grants
  • HealthWell Foundation: Rare disease medication assistance
  • National Organization for Rare Disorders: Financial aid programs

State Resources

Michigan residents may qualify for additional assistance through:

  • Michigan Department of Health and Human Services: Medicaid coverage expansion
  • Healthy Michigan Plan: Low-income coverage options

Counterforce Health can help identify all available assistance programs and ensure your applications highlight the strongest financial need arguments.

FAQ

How long does Humana prior authorization take for Firazyr? Standard decisions within 1-2 business days for complete electronic submissions. Expedited review available for urgent medical needs.

What if Firazyr is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Emphasize failed alternative therapies and HAE attack severity.

Can I get expedited appeals in Michigan? Yes. Michigan offers 72-hour expedited external review for urgent medical situations with physician attestation of harm risk.

Does step therapy apply to Firazyr with Humana? Some plans require trials of alternative HAE therapies first. Document all prior treatments and their outcomes to support Firazyr necessity.

What happens if my Humana claim is denied for self-administered drug exclusion? Appeal with documentation showing clinical administration necessity or request coverage under pharmacy benefit if available.

How do I find HAE specialists in Michigan for prior authorization? Contact the US Hereditary Angioedema Association for specialist referrals in your area.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions. For personalized assistance with prior authorizations and appeals, consider consulting with coverage advocacy services like Counterforce Health, which specializes in turning insurance denials into successful, evidence-backed appeals.

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