By Counterforce Health Team in Gamifant (emapalumab-lzsg) —

How to Get Gamifant (Emapalumab-lzsg) Covered by Humana in Virginia: Complete Guide with Forms and Appeal Process

Quick Answer: Getting Gamifant (Emapalumab-lzsg) Covered by Humana in Virginia

Fastest path to approval: Have your hematologist submit a prior authorization request to Humana with documented HLH-2004 criteria (5 of 8 required), genetic testing or family history, and evidence of conventional therapy failure. Submit via fax to 502-508-9300 with complete clinical documentation. If denied, you have 65 days to appeal, and Virginia offers external review through the State Corporation Commission within 120 days of final denial.

Start today: Contact your hematologist to begin gathering HLH diagnostic documentation and request the current Humana Gamifant prior authorization form.

Table of Contents

  1. Verify Your Plan and Find the Right Policy
  2. Required Forms and Documentation
  3. Submission Portals and Processes
  4. Fax and Mail Instructions
  5. Specialty Pharmacy Network
  6. Support Lines and Case Management
  7. Virginia Appeals and External Review
  8. Common Denial Reasons and Solutions
  9. When to Escalate in Virginia

Verify Your Plan and Find the Right Policy

Before starting your Gamifant (emapalumab-lzsg) prior authorization, confirm your specific Humana plan type and locate the current coverage policy.

Plan Types and Coverage:

  • Medicare Advantage: Follow Medicare Part B/D appeals process with 65-day deadlines
  • Commercial/Employer Plans: Standard internal appeals with Virginia external review rights
  • Medicaid (Healthy Horizons): 60-day appeal window with expedited options

Find your current Humana coverage policy for Gamifant by searching the Medical and Pharmacy Coverage Policies portal. The policy is actively maintained and updated as of September 2024.

Tip: Your insurance card should indicate whether you have Medicare Advantage, commercial, or Medicaid coverage. This determines which appeals process applies.

Required Forms and Documentation

Prior Authorization Form

Obtain the current Humana prior authorization form for professionally administered medications. The form requires:

  • Patient demographics and insurance information
  • Prescriber details including NPI number
  • HCPCS code J9210 for emapalumab-lzsg
  • Complete diagnosis and treatment history

Essential Clinical Documentation

HLH Diagnosis Confirmation (one of the following):

  • Molecular genetic testing showing HLH-causing mutations (PRF1, UNC13D, STX11, STXBP2, RAB27A, SH2D1A, NLRC4)
  • Family history consistent with primary HLH
  • At least 5 of 8 HLH-2004 criteria documented:
    • Fever
    • Splenomegaly
    • Cytopenias (≥2 lineages: Hb <9 g/dL, Platelets <100,000/µL, Neutrophils <1,000/µL)
    • Hypertriglyceridemia (≥265 mg/dL) and/or hypofibrinogenemia (≤150 mg/dL)
    • Hemophagocytosis in bone marrow, spleen, or lymph nodes
    • Low or absent NK cell activity
    • Ferritin ≥500 ng/mL
    • Elevated soluble CD25 (sIL-2 receptor α)

Treatment History:

  • Documentation of refractory, recurrent, or progressive disease after conventional HLH therapy
  • Evidence of intolerance to standard protocols (etoposide, dexamethasone, cyclosporine)
  • Hematologist confirmation of medical necessity

Submission Portals and Processes

Primary Submission Method

Fax: 502-508-9300 (verify current number with Humana provider services)

Include a cover sheet with:

  • Patient name and member ID
  • Provider name and NPI
  • Drug name: Gamifant (emapalumab-lzsg)
  • Urgency level (standard or expedited)

Online Options

Access prior authorization tools through the Humana provider portal. Create an account if you don't have one, and follow the professionally administered drug pathway.

Note: Always retain confirmation receipts and tracking numbers for all submissions.

Specialty Pharmacy Network

Gamifant requires coordination through Humana's specialty pharmacy network due to its complex administration requirements and monitoring protocols.

Enrollment Steps:

  1. Complete prior authorization approval
  2. Contact Humana Specialty Pharmacy Provider Line: 1-800-486-2668 (verify current number)
  3. Coordinate delivery to appropriate site of care (hospital, infusion center, or home)
  4. Establish case management for ongoing monitoring

Case Management Services:

  • Benefits verification and coverage coordination
  • Infection screening protocols (tuberculosis, herpes zoster)
  • Adverse event monitoring and reporting
  • Therapy compliance and renewal management

Support Lines and Case Management

Provider Support

  • General Pharmacy Provider Line: 1-800-555-CLIN (2546)
  • Specialty Pharmacy Support: 1-800-486-2668
  • Prior Authorization Status: Available through provider portal or phone

Member Support

  • Member Services: Number on back of insurance card
  • Pharmacy Benefits: 1-800-HUMANA (verify current number)

What to Ask When Calling:

  • Current status of prior authorization request
  • Required documentation still needed
  • Timeline for decision
  • Expedited review options if urgent
  • Case manager assignment for complex cases

Virginia Appeals and External Review

Internal Appeals with Humana

Medicare Advantage/Part D:

  • Timeline: 65 days from denial notice to file appeal
  • Decision: 7 days for standard, 72 hours for expedited
  • Method: Online, phone, or written request

Commercial Plans:

  • Timeline: Varies by plan, typically 60 days
  • Decision: 30 days standard, 72 hours expedited
  • Method: Follow plan-specific procedures

Virginia External Review Process

If Humana denies your internal appeal, Virginia law provides external review through the State Corporation Commission Bureau of Insurance.

Key Requirements:

  • File within 120 days of final Humana denial
  • Use Form 216-A (External Review Request)
  • Denial must be based on medical necessity, appropriateness, or experimental/investigational designation

Contact Information:

  • Address: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Phone: 1-877-310-6560
  • Fax: (804) 371-9915
  • Email: [email protected]

Required Attachments:

  • Copy of Humana's denial letter
  • Form 216-B if filing on behalf of someone else
  • Form 216-D if denial involves experimental/investigational determination

Download Form 216-A here

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
HLH diagnosis not confirmed Submit genetic testing or complete HLH-2004 criteria documentation Lab results, genetic reports, bone marrow biopsy
Lack of conventional therapy history Document prior treatment attempts and outcomes Progress notes showing etoposide, steroid trials
Missing specialist involvement Ensure hematologist is prescriber or consultant Referral letters, specialist consultation notes
Incomplete infection screening Provide tuberculosis and viral screening results TB testing, hepatitis panel, CMV status
Site of care not specified Clarify where drug will be administered Hospital admission orders or infusion center agreement

When to Escalate in Virginia

Contact Virginia Regulators When:

  • Humana fails to respond within required timeframes
  • You believe the denial violates Virginia insurance law
  • You need help understanding your appeal rights
  • The external review process isn't working properly

Virginia Resources:

  • Managed Care Ombudsman: 1-877-310-6560 (same as Bureau of Insurance)
  • Consumer Services: Assistance with understanding appeal processes
  • Virginia Poverty Law Center: Legal help for complex appeals (especially Medicaid cases)
From our advocates: We've seen success when families work closely with their hematologist to create a comprehensive narrative that clearly connects each HLH-2004 criterion to specific lab values and dates. One approach that works well is creating a timeline that shows conventional therapy attempts, their outcomes, and why Gamifant represents the appropriate next step based on current guidelines.

Counterforce Health: Turning Denials Into Approvals

When facing a Gamifant denial from Humana, Counterforce Health specializes in transforming insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes to identify the specific denial basis—whether PA criteria, step therapy, non-formulary status, or "not medically necessary" determinations—and drafts point-by-point rebuttals aligned to Humana's own rules.

For complex cases like Gamifant approvals, having the right evidence and documentation can make the difference between approval and denial. Counterforce Health helps clinicians and families navigate these challenging prior authorization processes with greater success rates.

Frequently Asked Questions

How long does Humana prior authorization take for Gamifant in Virginia? Standard decisions are made within 7-30 days depending on your plan type. Expedited reviews are available within 72 hours if delay could seriously harm your health.

What if Gamifant is not on Humana's formulary? You can request a formulary exception through the same prior authorization process. Include medical necessity documentation showing why covered alternatives are inappropriate.

Can I request an expedited appeal in Virginia? Yes, if your doctor certifies that waiting could seriously jeopardize your health. Both Humana and Virginia external review offer expedited timelines.

Does step therapy apply to Gamifant? Most plans require documentation of conventional HLH therapy attempts (etoposide, steroids) before approving Gamifant, unless contraindicated or not tolerated.

What happens if Virginia external review denies my case? The IRO decision is final and binding, but you retain rights to pursue legal action if you believe laws were violated.

Update Cadence and Staying Current

Insurance policies and forms change frequently. Check for updates:

  • Quarterly: Review Humana's coverage policies for any criteria changes
  • Annually: Verify contact numbers and submission processes
  • When denied: Confirm you're using the most current forms and procedures

Always verify phone numbers and submission addresses directly with Humana, as these can change without notice.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current insurance policies and procedures with Humana directly. Coverage policies and contact information may change without notice.

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