By Counterforce Health Team in Gattex (teduglutide) —

How to Get Gattex (teduglutide) Covered by Humana in Michigan: Forms, Appeals, and Provider Scripts

Quick Answer: Getting Gattex Covered by Humana in Michigan

Gattex (teduglutide) requires prior authorization from Humana for short bowel syndrome with parenteral nutrition dependence. Your fastest path: Have your gastroenterologist submit a PA request via Humana's electronic portal with complete documentation (SBS diagnosis with ICD-10 K90.82, current PN regimen details, failed enteral therapies, and recent colonoscopy). Humana commits to 1-business-day decisions for complete electronic requests by 2026. If denied, you have 65 days to appeal and can request Michigan's external review within 127 days for a binding decision.

Start today: Call Humana at 800-867-6601 to confirm your plan's formulary status and get the current PA portal link.

Table of Contents

  1. Before You Start: Plan and Coverage Verification
  2. What You Need to Gather
  3. Submit Your Prior Authorization Request
  4. Follow-Up and Timelines
  5. Handling Information Requests
  6. If Your Request is Denied
  7. Renewal and Re-authorization
  8. Common Denial Reasons and Solutions
  9. Appeals Process in Michigan
  10. Quick Reference Checklist
  11. FAQ

Before You Start: Plan and Coverage Verification

Confirm Your Humana Plan Type

Gattex coverage varies by plan type. Check your member ID card for:

  • Medicare Advantage (Part C) or Part D: Most Gattex approvals fall under Part D pharmacy benefits
  • Commercial/Employer: Different PA requirements may apply
  • Medicaid/Dual Eligible: Michigan Medicaid expansion may have specific protocols
Tip: Call the number on your ID card to confirm which benefit covers Gattex for your specific plan.

Verify Formulary Status

Use Humana's Drug List search tool to check:

  • Formulary tier placement
  • Prior authorization requirements
  • Step therapy protocols
  • Quantity limits
  • Preferred specialty pharmacy requirements

Specialty Pharmacy Requirements

Humana typically requires Gattex to be dispensed through CenterWell Specialty Pharmacy rather than retail pharmacies. Call 844-486-2668 to confirm network status and home delivery to your Michigan address.

What You Need to Gather

Clinical Documentation Checklist

Diagnosis Requirements:

  • Short bowel syndrome diagnosis with ICD-10 code K90.82, K90.821, or K90.822
  • Operative reports showing resection details and remaining bowel length
  • Documentation of colon-in-continuity status

Parenteral Nutrition Evidence:

  • Current PN regimen (volume, days per week, calories, duration)
  • PN logs showing dependence for ≥12 months
  • Documentation of failed enteral nutrition attempts
  • Weight trends and nutritional status

Safety Screening:

  • Recent colonoscopy results (required due to Gattex's boxed warning)
  • Cancer screening documentation
  • Baseline labs (liver function, electrolytes, albumin)

Prior Therapies:

  • Failed medications (antidiarrheals, antisecretory agents)
  • Dietary modifications attempted
  • Previous surgical interventions
Note: Counterforce Health helps patients and clinicians compile evidence-backed appeals by identifying specific denial reasons and matching them with the right clinical evidence and policy citations.

Submit Your Prior Authorization Request

Electronic Submission (Preferred)

Humana prioritizes electronic prior authorization (ePA) and commits to 1-business-day decisions for complete requests by January 2026. Access through:

Alternative Submission Methods

Phone: 800-867-6601 for Part D appeals and PA inquiries

Fax/Mail: Use forms from Humana's PA resources (verify current fax number on the form)

Medical Necessity Letter Components

Your gastroenterologist should include:

  1. Patient identification and Humana member ID
  2. Primary diagnosis: Short bowel syndrome (K90.82) with underlying etiology
  3. Clinical history: Surgical details, remaining bowel length, adaptation period
  4. Current status: PN dependence documentation with specific regimen details
  5. Failed therapies: Enteral nutrition trials, medications, dietary modifications
  6. Treatment goals: Specific PN reduction targets and monitoring plan
  7. Safety considerations: Cancer screening completion and monitoring plan

Follow-Up and Timelines

Standard Timelines

Coverage Determinations:

  • Standard requests: 72 hours
  • Expedited requests: 24 hours

Part D Appeals:

  • Standard: 7 calendar days
  • Expedited: 72 hours maximum

When to Follow Up

  • Day 3: Call to confirm receipt if no acknowledgment
  • Day 5: Request status update for standard requests
  • Day 1: Follow up on expedited requests if no response

Sample Follow-Up Script

"This is [name] calling about prior authorization request [reference number] for Gattex submitted on [date]. Can you confirm the status and expected decision timeline? If additional information is needed, what specifically is required?"

Handling Information Requests

Common Additional Information Requests

PN Documentation Gaps:

  • Submit detailed PN logs with volumes and frequencies
  • Provide nutrition assessment from registered dietitian
  • Include catheter access history and complications

Insufficient Safety Screening:

  • Provide colonoscopy report with polyp removal documentation
  • Submit GI oncology consultation if cancer history exists
  • Include imaging studies showing bowel anatomy

Prior Therapy Documentation:

  • Detailed medication trial log with doses, durations, and outcomes
  • Enteral nutrition attempts with specific formulas and routes tried
  • Surgical consultation notes regarding additional interventions

If Your Request is Denied

Understanding Denial Letters

Humana denial letters specify:

  • Exact reason for denial
  • Required additional documentation
  • Appeal rights and deadlines
  • Contact information for questions

First-Level Appeal Strategy

Within 65 days of denial:

  1. Request peer-to-peer review with Humana medical director
  2. Submit additional clinical evidence addressing specific denial reasons
  3. Include updated clinical status and PN reduction attempts

Sample Peer-to-Peer Request: "I'm requesting a peer-to-peer review for [patient name], member ID [number], regarding the Gattex prior authorization denial dated [date]. The patient has documented short bowel syndrome with ongoing PN dependence despite optimization. I can provide additional clinical details and discuss treatment rationale."

Renewal and Re-authorization

Timing Your Renewal

Submit renewal requests 30-45 days before current authorization expires. Humana typically approves Gattex for 6-12 month periods.

Renewal Documentation Requirements

Clinical Response Evidence:

  • PN volume or frequency reductions achieved
  • Weight stabilization or improvement
  • Reduced hospitalizations or catheter complications
  • Quality of life improvements

Ongoing Safety Monitoring:

  • Updated colonoscopy if due
  • Current lab values showing stability
  • Documentation of continued medical necessity

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient PN dependence evidence Submit detailed PN logs 6+ months of PN records with volumes/frequencies
Missing safety screening Complete cancer screening Recent colonoscopy report, GI consultation
Inadequate prior therapy trials Document failed treatments Medication trial log with specific outcomes
Non-formulary status Request formulary exception Medical necessity letter with alternative failures
Quantity limit exceeded Justify dose requirements Weight-based dosing calculation, label reference

Appeals Process in Michigan

Internal Appeal (Required First Step)

Timeline: Must file within 65 days of denial Process: Submit through Humana's standard appeal channels Decision time: 7 days for Part D appeals

Michigan External Review

If Humana's internal appeal is denied, Michigan offers independent external review:

Timeline: 127 days from final internal denial to file with Michigan DIFS Process: Submit External Review Request form online or by mail Decision time: 60 days maximum (72 hours for expedited) Cost: No fee to patient Binding: Yes, insurers must comply with favorable decisions

Contact Michigan DIFS: 877-999-6442 for appeal assistance

Expedited External Review

Available when delay would seriously jeopardize health. Requires physician letter documenting urgency and 72-hour decision timeframe.

At this point, many patients find that specialized support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing the specific denial basis and crafting point-by-point rebuttals using the plan's own criteria and relevant clinical evidence.

Quick Reference Checklist

Before Submitting:

  • Verify Humana plan covers Gattex under Part D
  • Confirm specialty pharmacy network requirements
  • Gather SBS diagnosis with ICD-10 codes
  • Document PN dependence with detailed logs
  • Complete cancer screening requirements
  • Compile failed therapy documentation

Submission:

  • Use electronic portal when possible
  • Include complete medical necessity letter
  • Attach all supporting documentation
  • Request expedited review if clinically urgent
  • Document submission date and reference number

Follow-Up:

  • Call within 3 days to confirm receipt
  • Track decision timeline
  • Prepare appeal documentation if denied
  • Calendar renewal dates for ongoing therapy

FAQ

How long does Humana prior authorization take for Gattex in Michigan? Standard requests receive decisions within 72 hours for coverage determinations and 7 days for Part D appeals. Expedited requests are decided within 24-72 hours.

What if Gattex is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation showing why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal if I'm already on Gattex? Yes, if interruption of therapy would seriously jeopardize your health. Your physician must document the medical urgency.

Does step therapy apply to Gattex for short bowel syndrome? Step therapy requirements vary by plan. Most require documentation of failed enteral nutrition optimization before approving Gattex.

What happens if Humana denies my appeal in Michigan? You can file for external review with Michigan DIFS within 127 days. This independent review is binding on Humana.

How often do I need to renew Gattex authorization? Typically every 6-12 months, with documentation of continued clinical response and PN reduction progress.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not replace professional medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and review your specific plan documents. For personalized assistance with complex appeals, consider consulting with insurance advocacy services.

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