By Counterforce Health Team in Gattex (teduglutide) —

How to Get Gattex (teduglutide) Covered by Humana in California: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Gattex (teduglutide) Covered by Humana in California

Fastest path to approval: Submit prior authorization using Humana's California-specific PA form with detailed short bowel syndrome documentation. If denied, file internal appeal within 65 days, then escalate to California's Independent Medical Review (IMR) through DMHC at 1-888-466-2219. Start today: Verify if Gattex requires PA using Humana's search tool, then gather SBS diagnosis records, parenteral nutrition logs, and prior therapy documentation.

Table of Contents

  1. Start Here: Verify Your Plan & Requirements
  2. Required Forms & Documentation
  3. Submission Portals & Methods
  4. Fax Numbers & Mailing Addresses
  5. CenterWell Specialty Pharmacy Setup
  6. Support Phone Lines
  7. California Appeals & External Review
  8. Common Denial Reasons & Solutions
  9. Timeline & Next Steps
  10. FAQ

Start Here: Verify Your Plan & Requirements

Before submitting any paperwork, confirm whether Gattex (teduglutide) requires prior authorization for your specific Humana plan. Use Humana's Prior Authorization Search Tool to check current requirements.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for most Humana plans PA Search Tool Humana Provider Portal
Medical Necessity SBS diagnosis with PN dependence Clinical documentation FDA Label
Step Therapy May require nutrition optimization first Plan-specific policy Humana Drug Lists
Specialty Pharmacy Must use CenterWell or approved network Pharmacy directory CenterWell Specialty
Appeals Deadline 65 days from denial (Medicare) Member handbook Humana Appeals Process

Required Forms & Documentation

Primary Form

Use the California Prescription Drug Prior Authorization Request Form for all Gattex requests. This state-specific form is mandatory for California residents with Humana coverage.

Download: California PA Request Form (PDF)

Required Clinical Documentation

Essential Elements for Medical Necessity:

  • Confirmed short bowel syndrome diagnosis with ICD-10 code
  • Current parenteral nutrition requirements (volume, frequency, duration)
  • Documentation of PN dependence despite enteral nutrition optimization
  • Prior therapy attempts and outcomes
  • Prescriber attestation of medical necessity
  • Treatment goals and monitoring plan
Clinician Corner: Your medical necessity letter should address why Gattex is specifically needed for this patient's SBS management. Include baseline PN requirements, previous attempts at enteral nutrition optimization, and expected treatment outcomes. Reference the FDA-approved indication for SBS patients requiring parenteral support.

Supporting Documents Checklist:

  • Recent clinic notes (within 30 days)
  • Laboratory results showing nutritional status
  • PN logs documenting current requirements
  • Previous treatment history and failures
  • Specialist consultation notes (if applicable)

Submission Portals & Methods

Electronic Submission

  • Provider Portal: Availity Essentials for healthcare providers
  • CoverMyMeds: Electronic PA platform integrated with many EHR systems
  • Member Portal: MyHumana for patient-initiated requests

Manual Submission Options

Fax: 1-877-486-2621 (primary PA fax line)
Phone: 1-800-555-2546 (PA assistance line)

Tip: Electronic submissions through CoverMyMeds or the provider portal typically process faster than fax submissions and provide real-time status updates.

Fax Numbers & Mailing Addresses

Key Contact Information

Purpose Contact Method Details
Prior Authorization Fax 1-877-486-2621
PA Phone Support Phone 1-800-555-2546
Specialty Pharmacy Rx Fax 1-877-405-7940
Case Management Phone 1-800-486-2668 (TTY: 711)
Member Appeals Online/Phone MyHumana or member ID card number

Mailing Address for Appeals

Humana Inc.
Pharmacy Appeals Department
P.O. Box 14601
Lexington, KY 40512

CenterWell Specialty Pharmacy Setup

Gattex must be dispensed through a specialty pharmacy. Humana primarily uses CenterWell Specialty Pharmacy for covered specialty medications.

Setup Process:

  1. Provider Action: Submit prescription to CenterWell via fax (1-877-405-7940) or e-prescribe
  2. Patient Enrollment: CenterWell will contact patient to complete intake
  3. Insurance Verification: Pharmacy confirms coverage and copay
  4. Delivery Coordination: Arrange home delivery or clinic pickup

CenterWell Specialty Pharmacy Contact:
Phone: 1-800-486-2668
Hours: Monday–Friday 8 a.m.–11 p.m., Saturday 8 a.m.–6:30 p.m. (Eastern)

Support Phone Lines

When to Call Each Number

Member Services: Use the phone number on your Humana ID card

  • Plan benefits questions
  • Coverage verification
  • General appeals assistance

Provider Support: 1-800-379-0092

  • PA status checks
  • Clinical policy questions
  • Network pharmacy verification

Specialty Pharmacy: 1-800-486-2668

  • Prescription status
  • Financial assistance programs
  • Clinical support services

California Appeals & External Review

If Humana denies your Gattex prior authorization, California residents have strong appeal rights through the state's Independent Medical Review (IMR) system.

Step-by-Step Appeals Process

Step 1: Internal Appeal with Humana

  • Deadline: 65 days from denial notice (Medicare plans)
  • Method: Online portal, phone, or written request
  • Timeline: 7 days for standard review, 72 hours for expedited

Step 2: California IMR (External Review)

  • Trigger: After internal appeal denial or 30+ days without resolution
  • Contact: DMHC Help Center at 1-888-466-2219
  • Apply Online: healthhelp.ca.gov
  • Cost: Free to patients
  • Timeline: 30-45 days standard, 3-7 days expedited
Note: California's IMR system has a 68% success rate for specialty drug appeals. Independent physicians review your case and make binding decisions that Humana must follow.

Required IMR Documentation:

  • Humana's complete denial letter
  • Physician's detailed medical necessity letter
  • Clinical records supporting SBS diagnosis
  • Scientific evidence for Gattex efficacy
  • Documentation of failed alternatives

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Not medically necessary" Submit detailed SBS documentation, PN logs, and specialist attestation
"Experimental/investigational" Provide FDA approval letter and clinical guidelines supporting use
"Step therapy not completed" Document failed enteral nutrition optimization attempts
"Quantity limits exceeded" Justify dosing based on patient weight and FDA guidelines
"Non-formulary drug" Request formulary exception with comparative effectiveness data

Script for Peer-to-Peer Review Request

"I'm requesting a peer-to-peer review for my patient with short bowel syndrome who requires Gattex (teduglutide). The patient has documented PN dependence despite optimal enteral nutrition, and Gattex is FDA-approved for this exact indication. Can we schedule a clinical discussion with your medical director?"

Timeline & Next Steps

Typical Timeline for Gattex Approval:

  1. PA Submission: 1-3 business days to prepare and submit
  2. Initial Review: 5-14 business days for Humana decision
  3. If Denied - Internal Appeal: 7-30 days depending on urgency
  4. If Still Denied - IMR: 30-45 days for final decision
  5. If Approved: 5-10 business days for specialty pharmacy setup

Immediate Action Items:

  • Check PA requirement using Humana's search tool
  • Gather all SBS diagnostic documentation
  • Compile PN logs and prior therapy records
  • Complete California PA request form
  • Submit through preferred method (electronic preferred)

For complex cases or urgent situations, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting targeted, evidence-backed rebuttals that align with each plan's specific requirements.

FAQ

Q: How long does Humana prior authorization take in California?
A: Standard PA reviews take 5-14 business days. Expedited reviews (for urgent medical situations) are completed within 72 hours.

Q: What if Gattex isn't on Humana's formulary?
A: Request a formulary exception using the same PA form. Include comparative effectiveness data showing why formulary alternatives are inadequate for your condition.

Q: Can I get financial assistance for Gattex copays?
A: Yes. Contact CenterWell Specialty Pharmacy at 1-800-486-2668 to explore manufacturer copay programs and foundation grants.

Q: What counts as medical necessity for Gattex?
A: FDA-approved indication requires SBS diagnosis with dependence on parenteral nutrition or IV fluids. Document current PN requirements and failed enteral optimization attempts.

Q: How do I request an expedited appeal?
A: Contact Humana immediately if denial creates urgent health risk. Expedited appeals are decided within 72 hours with proper clinical justification.

Q: What if I miss the appeal deadline?
A: Contact DMHC Help Center at 1-888-466-2219. California may allow late appeals in certain circumstances, especially for urgent medical needs.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance plan. For personalized assistance with complex appeals, organizations like Counterforce Health can help analyze your specific situation and develop targeted appeal strategies.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.