By Counterforce Health Team in Gattex (teduglutide) —

How to Get Gattex (Teduglutide) Covered by Humana in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Gattex Covered by Humana in Georgia

Eligibility: Humana covers Gattex (teduglutide) for short bowel syndrome patients requiring parenteral nutrition ≥3x/week for ≥3 months. Fastest path: Submit prior authorization through CoverMyMeds with complete PN logs, specialist notes, and failed enteral therapy documentation. Start today: Have your gastroenterologist gather your PN records and submit the PA electronically—processing takes 5-14 business days standard, 72 hours expedited. If denied, you have 65 days to appeal internally, then 60 days for Georgia external review through the Georgia Department of Insurance.

Table of Contents

  1. Verify Your Plan & Find Current Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Options
  4. Fax & Mail Submission Details
  5. CenterWell Specialty Pharmacy Setup
  6. Support Lines & Contact Directory
  7. Georgia Appeals & External Review
  8. Common Denial Reasons & Solutions
  9. Medical Necessity Letter Checklist
  10. FAQ

1. Verify Your Plan & Find Current Forms

Before starting your Gattex prior authorization, confirm your specific Humana plan type and current requirements:

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Gattex prescriptions Humana PA Search Tool Humana Provider Portal
Formulary Status Typically Tier 5 (specialty) MyHumana member portal Member Benefits
Step Therapy May require enteral optimization first PA form clinical section Plan Policy
Quantity Limits Based on weight/dosing requirements Pharmacy benefits summary Member Handbook
Site of Care Home injection (specialty pharmacy) CenterWell Specialty Humana Network

Action Step: Log into your MyHumana account or call the number on your member ID card to verify your specific plan's requirements.

2. Prior Authorization Forms & Requirements

Current Humana PA Form (2024-2025)

Humana uses their standard pharmacy prior authorization process for Gattex. There's no separate Gattex-specific form, but you'll need:

  • Standard Form: Humana Pharmacy Prior Authorization Form
  • Georgia Exception: No special state form required (unlike California)
  • Current Version: Always download fresh from the portal—forms update quarterly

Required Clinical Documentation

Your submission must include:

Diagnosis Requirements:

  • Confirmed short bowel syndrome with appropriate ICD-10 code
  • Documentation of remaining small bowel length (if available)
  • Underlying cause of SBS (surgical, congenital, disease-related)

Parenteral Nutrition Documentation:

  • Current PN regimen details (volume, frequency, calories)
  • Duration of PN dependence (minimum 3 months at ≥3x/week)
  • PN logs showing consistent usage patterns
  • Recent nutritional assessments and lab values

Prior Therapy Evidence:

  • Attempts at enteral nutrition optimization
  • Dietary modifications and outcomes
  • Other SBS management strategies tried and failed
  • Contraindications to alternative approaches
Tip: Keep detailed PN logs for at least 90 days before applying. Humana reviewers specifically look for consistent PN dependence patterns.

3. Submission Portals & Electronic Options

CoverMyMeds (Fastest Processing):

  • URL: CoverMyMeds Humana Portal
  • Real-time status updates
  • Direct integration with EHR systems
  • Average processing: 3-5 business days

Availity Essentials Provider Portal:

  • Primary Humana provider portal
  • Requires provider registration and login
  • Upload supporting documents directly
  • Track submission status online

MyHumana Patient Portal:

  • Limited PA initiation capabilities
  • Better for status checks and appeals
  • Requires member account setup

Required Portal Setup

  1. For Providers: Register at Availity with NPI and practice details
  2. For Patients: Create MyHumana account with member ID
  3. Upload Requirements: PDF format, max 10MB per document
  4. Status Monitoring: Check portal notifications for requests for additional information

4. Fax & Mail Submission Details

Fax Submission

Primary PA Fax: 1-877-486-2621 Cover Sheet Requirements:

  • Member name and ID
  • Provider name and NPI
  • "GATTEX PRIOR AUTHORIZATION" in subject line
  • Page count and date

Fax Tips:

  • Send during business hours for faster processing
  • Use high-resolution settings
  • Include return fax number for questions
  • Keep confirmation receipt

Mail Submission

Address: Humana Pharmacy Prior Authorization P.O. Box 14546 Lexington, KY 40512-4546

Mailing Tips:

  • Use certified mail for important deadlines
  • Include return envelope if response needed
  • Allow 7-10 business days for mail processing

5. CenterWell Specialty Pharmacy Setup

Onboarding Process

Gattex is dispensed exclusively through CenterWell Specialty Pharmacy, Humana's specialty network provider.

Step 1: Prescription Submission

  • Provider e-prescribes to CenterWell
  • Fax: 1-877-405-7940
  • Phone: 1-800-486-2668

Step 2: Patient Registration

  • CenterWell contacts patient within 24-48 hours
  • Complete intake interview
  • Schedule delivery and training

Step 3: Prior Authorization Coordination

  • CenterWell handles PA submission if not already approved
  • Provides status updates to patient and provider
  • Manages appeals if needed

Georgia Delivery Details

  • Coverage Area: Statewide mail delivery
  • Shipping: Temperature-controlled overnight delivery
  • Training: Phone-based injection instruction
  • Ongoing Support: 24/7 clinical support line

From our advocates: We've seen patients successfully start Gattex within 7-10 days when the provider coordinates PA submission with CenterWell enrollment simultaneously. This parallel approach prevents delays between approval and first shipment, which is especially important for patients with declining nutritional status.

6. Support Lines & Contact Directory

Member Services

General Customer Service: 1-800-457-4708 (TTY: 711)

  • Hours: Monday-Friday, 8 AM-8 PM local time
  • Services: Benefits verification, claim status, general questions

Prior Authorization Status: 1-866-773-5959

  • Real-time PA status updates
  • Expected decision timelines
  • Required additional documentation

Provider Services

Provider Customer Service: 1-800-555-2546

  • PA assistance and submission support
  • Policy clarification
  • Peer-to-peer review requests

Prior Authorization Line: 1-866-488-5995

  • Provider-specific PA inquiries
  • Clinical review discussions
  • Expedited request processing

Specialty Pharmacy Support

CenterWell Specialty: 1-800-486-2668

  • Hours: Monday-Friday 8 AM-11 PM, Saturday 8 AM-6:30 PM Eastern
  • Patient enrollment and support
  • Medication management
  • Financial assistance programs

What to Ask When Calling

For PA Status Inquiries:

  • Reference number or confirmation code
  • Expected decision date
  • Any missing documentation
  • Next steps if additional info needed

For Denials:

  • Specific denial reason
  • Required documentation for appeal
  • Expedited appeal options
  • Peer-to-peer review availability

7. Georgia Appeals & External Review

Internal Appeal Process

Timeline: 65 days from denial notice date Form: Humana Grievance/Appeal Request Form Submission Address: Humana Grievance and Appeal Department P.O. Box 14546 Lexington, KY 40512-4546

Decision Timeline:

  • Pre-service appeals: 30 days
  • Post-service appeals: 60 days
  • Expedited appeals: 72 hours

Georgia External Review

If Humana denies your internal appeal, Georgia law provides an independent external review option.

Eligibility: Medical necessity denials, experimental/investigational determinations Timeline: 60 days from final internal appeal denial Cost: Free to consumer

How to Request External Review:

  1. Download application from Georgia DOI website
  2. Submit to Georgia Office of Commissioner of Insurance and Fire Safety
  3. Include all denial letters and supporting documentation
  4. Request expedited review if medically urgent

Contact for Assistance:

  • Georgia DOI Consumer Services: 1-800-656-2298
  • Online complaint form available
  • Georgians for a Healthy Future (nonprofit assistance)

Decision Timeline:

  • Standard review: 30 business days
  • Expedited review: 72 hours
  • Decision is binding on Humana
Note: Georgia's external review process has a strong track record for specialty drug appeals. The independent medical reviewers often overturn denials when proper clinical documentation supports medical necessity.

8. Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient PN documentation Provide detailed logs 90+ days of PN records showing ≥3x/week usage
Lack of enteral optimization Document failed attempts Dietitian notes, enteral trial records, intolerance documentation
Missing specialist evaluation Obtain GI consultation Gastroenterologist assessment and treatment plan
Inadequate diagnosis coding Correct ICD-10 codes Specific SBS codes with underlying etiology
Quantity over limits Justify dosing Weight-based calculations, FDA dosing guidelines
Site of care restrictions Request exception Medical necessity for home vs. clinic administration

Counterforce Health's Expertise

When facing complex denials or multiple appeal levels, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with Humana's specific requirements, pulling appropriate FDA labeling, peer-reviewed studies, and specialty guidelines to support Gattex approvals.

9. Medical Necessity Letter Checklist

Clinician Corner: Essential Elements

Your medical necessity letter should address each of these components:

Clinical Problem:

  • Short bowel syndrome diagnosis with specific etiology
  • Remaining bowel length and functional capacity
  • Current nutritional status and deficiencies
  • Impact on quality of life and daily functioning

Prior Treatment History:

  • Detailed enteral nutrition attempts
  • Dietary modifications and specialized formulas
  • Anti-diarrheal medications and other supportive care
  • Surgical interventions (if applicable)
  • Outcomes and reasons for failure/intolerance

Medical Necessity for Gattex:

  • FDA-approved indication alignment
  • Expected clinical benefits (PN reduction, improved absorption)
  • Monitoring plan and success metrics
  • Contraindications to alternative therapies

Supporting Evidence:

  • Reference FDA prescribing information
  • Cite relevant clinical guidelines (ASPEN, ACG)
  • Include recent lab values and nutritional assessments
  • Document PN dependence with specific volumes/frequencies

Treatment Plan:

  • Dosing rationale based on weight
  • Injection training and compliance plan
  • Follow-up schedule and monitoring parameters
  • Goals for PN reduction over time

10. FAQ

How long does Humana PA take for Gattex in Georgia? Standard processing is 5-14 business days via electronic submission, 72 hours for expedited requests when medically urgent. CoverMyMeds typically processes fastest at 3-5 days.

What if Gattex is non-formulary on my plan? Request a formulary exception using the same PA process. Provide medical necessity documentation showing why formulary alternatives are inappropriate or contraindicated.

Can I request an expedited appeal if denied? Yes, if your medical condition could seriously deteriorate without Gattex. Contact Humana at 1-866-773-5959 to request expedited processing within 72 hours.

Does step therapy apply if I failed treatments in another state? Georgia residency doesn't affect step therapy requirements. Document all prior treatments regardless of where they occurred—Humana accepts out-of-state medical records.

What's the cost difference between approval levels? With PA approval, your cost depends on your plan's specialty tier copay or coinsurance. Without approval, you'd pay the full cash price of approximately $46,893 per 30-vial kit.

How do I transfer from another specialty pharmacy? Contact CenterWell at 1-800-486-2668 to initiate transfer. They'll coordinate with your current pharmacy and ensure no gap in therapy during the transition.

What if I need Gattex while traveling outside Georgia? CenterWell can coordinate temperature-controlled shipping to temporary addresses. Provide 7-10 days notice for travel arrangements and ensure proper storage during transport.

Can family members help with my appeal? Yes, but you must complete an Authorized Representative form allowing them to speak with Humana on your behalf. This form is available through your MyHumana portal.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider about treatment options and contact Counterforce Health or your insurance company directly for plan-specific guidance. For additional consumer assistance in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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