By Counterforce Health Team in Gattex (teduglutide) —

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

Getting Gattex (teduglutide) covered by Humana in Texas requires prior authorization with documented short bowel syndrome, parenteral nutrition dependence logs, and specialist involvement. Standard PA decisions take 7 calendar days; expedited reviews complete within 72 hours. If denied, you have 65 days to file internal appeals, with external review available through Medicare's Independent Review Entity.

Fastest path to approval: (1) Gather 3+ months of detailed PN logs showing volume and frequency, (2) obtain gastroenterologist consultation notes confirming SBS diagnosis, and (3) submit complete PA request through Humana's provider portal with baseline colonoscopy results.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana plans Humana PA Lists Humana Provider
Formulary Status May be non-formulary; exceptions available Humana Drug Lists Humana Pharmacy
Diagnosis Short bowel syndrome (ICD-10 K91.2) Medical records, specialist notes Clinical Documentation
PN Dependence ≥3 days/week for ≥3 months Detailed nutrition logs Hospital/clinic records
Age Requirement ≥1 year old Patient chart Medical records
Specialist Gastroenterologist consultation required Referral notes, consultation Provider documentation
Appeals Deadline 65 days from denial (Medicare) Denial letter Medicare Appeals Process

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your PA request, gather these critical documents:

Clinical Requirements:

  • Short bowel syndrome diagnosis with ICD-10 code K91.2
  • Detailed parenteral nutrition logs showing volume, frequency, and duration for at least 3 months
  • Specialist consultation notes from gastroenterologist or GI surgeon
  • Recent colonoscopy results (within 6 months for patients ≥18 years)
  • Complete blood count and comprehensive metabolic panel
  • Liver function tests and nutritional assessments

Insurance Information:

  • Current Humana member ID and plan details
  • Prescriber NPI and DEA numbers
  • Preferred specialty pharmacy information
Tip: Call Humana member services at 1-800-457-4708 to verify your current formulary status and PA requirements before submitting.

Verify Coverage Details

Contact Humana to confirm:

  • Whether Gattex is on your plan's formulary
  • Current tier placement and any quantity limits
  • Preferred specialty pharmacy network
  • Any plan-specific documentation requirements

Submission to Initial Review (1-7 Days)

How to Submit Your Prior Authorization

Primary Method - Electronic Portal: Submit through Humana's provider portal or CoverMyMeds for fastest processing and real-time tracking.

Alternative Methods:

  • Fax: 1-877-486-2621 (verify current number with Humana)
  • Phone: 1-800-555-2546 for urgent cases

What Reviewers Check First

Humana's utilization management team initially screens for:

  1. Complete PA form with all required fields
  2. Valid diagnosis code (K91.2 for short bowel syndrome)
  3. Parenteral nutrition documentation showing dependence pattern
  4. Specialist involvement confirmation
  5. Age and weight requirements (≥1 year, ≥10 kg)
Note: Under new CMS regulations effective January 2026, Humana must provide PA decisions within 7 calendar days for standard requests and 72 hours for expedited requests.

Additional Information Requests (1-7 Days)

Responding to Information Requests

If Humana requests additional documentation, you typically have 5-10 business days to respond. Common requests include:

Missing Information Required Response Submission Method
Inadequate PN logs 3+ months detailed volume/frequency records Portal upload or secure fax
Missing colonoscopy Procedure report with polyp removal documentation Provider portal with pathology results
Insufficient specialist notes GI consultation with treatment plan Secure provider communication
Baseline labs incomplete CBC, CMP, LFTs, nutritional markers Lab results portal or fax

Avoiding Hold Queues

To prevent delays:

  • Submit complete documentation initially
  • Respond to requests within 48 hours when possible
  • Use electronic submission methods for faster processing
  • Include cover letters summarizing key clinical points

Decision Window & Reading Approval Letters

Typical Approval Timeline

Standard Reviews: 7 calendar days from complete submission Expedited Reviews: 72 hours for urgent medical necessity

Understanding Approval Letters

When approved, your letter will specify:

  • Approval duration (typically 6-12 months initially)
  • Approved quantity and refill limits
  • Dispensing pharmacy requirements
  • Monitoring requirements for reauthorization

Partial Approvals

Humana may approve with modifications:

  • Reduced quantity limits
  • Shorter approval periods
  • Specific monitoring requirements
  • Alternative dosing schedules

If Denied: Appeals Timeline in Texas

Internal Appeals Process

Level 1 - Plan Review (65 days to file):

  • File through Humana member portal or call 1-866-347-9507
  • Include updated medical records and physician letter of medical necessity
  • Decision timeline: 7 days standard, 72 hours expedited

Required Documentation for Appeals:

  • Copy of original denial letter
  • Additional clinical evidence supporting medical necessity
  • Physician attestation of urgency (for expedited appeals)
  • Documentation of failed alternatives or contraindications

External Review Options

Medicare Advantage Plans: If internal appeals are denied, your case automatically advances to an Independent Review Entity (IRE) like Maximus Federal. No additional filing required.

Texas State External Review: For non-Medicare plans, Texas offers independent external review through the Texas Department of Insurance:

  • File within 4 months of final denial
  • No cost to patient
  • Decision within 20 days (5 days for urgent cases)
  • Binding decision - insurers must comply if overturned
From our advocates: We've seen Gattex appeals succeed most often when the submission includes quantitative PN reduction goals (like "reduce from 5 days/week to 3 days/week within 6 months") and documents specific failed attempts at enteral nutrition optimization. This gives reviewers concrete metrics to evaluate medical necessity.

Renewal Cycles & Reauthorization

When to Submit Renewals

Begin reauthorization 30-45 days before your current approval expires to avoid treatment interruptions.

Renewal Documentation Requirements

Requirement Initial PA Renewal PA
Duration 6-12 months 12 months
PN Evidence Baseline logs ≥20% volume reduction OR ≥1 day/week decrease
Clinical Response N/A Documented improvement in nutritional status
Monitoring Baseline screening Updated labs, colonoscopy as indicated

Factors That Speed Renewals

  • Quantified improvement: Document specific PN reductions
  • Stable dosing: No dose changes or interruptions
  • Good tolerance: No significant adverse events
  • Continued specialist oversight: Recent GI follow-up notes

Timeline Visual & Milestones

Milestone Timeline Key Actions
Pre-submission Days 0-2 Gather PN logs, specialist notes, lab results
Submission Day 1 Submit complete PA via portal or CoverMyMeds
Initial Review Days 1-7 Humana reviews for completeness and criteria
Additional Info Days 1-7 Respond to any documentation requests
Decision Day 7 (standard) / 72 hours (expedited) Approval, denial, or partial approval issued
If Denied Within 65 days File internal appeal with additional evidence
External Review Automatic (Medicare) / 4 months (commercial) Independent review of denial

Time-Saving Tips for Faster Approval

Portal Usage Best Practices

  • Use CoverMyMeds for real-time status tracking and faster processing
  • Upload all documents in a single submission to avoid delays
  • Include cover letters summarizing key clinical points for reviewers

Bundled Evidence Strategy

Submit comprehensive documentation packages including:

  • Complete PA form with all fields populated
  • Specialist consultation notes and treatment plan
  • 3+ months of detailed PN logs with volumes and frequencies
  • Recent lab results and colonoscopy reports
  • Letter of medical necessity with specific clinical rationale

Direct Specialty Routing

  • Identify preferred specialty pharmacies in Humana's network before approval
  • Coordinate with pharmacy for seamless transition post-approval
  • Verify refrigerated shipping capabilities for temperature-sensitive medications

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. Their platform identifies specific denial reasons and drafts point-by-point rebuttals aligned with each payer's requirements, significantly improving approval rates for specialty medications like Gattex.

FAQ

How long does Humana prior authorization take for Gattex in Texas? Standard PA decisions are completed within 7 calendar days under new CMS regulations. Expedited reviews for urgent cases are completed within 72 hours.

What if Gattex is non-formulary on my Humana plan? You can request a formulary exception by documenting why formulary alternatives are inappropriate. Submit evidence that standard treatments have failed or are contraindicated.

Can I request an expedited appeal if my Gattex is denied? Yes, if a delay would seriously jeopardize your health or functional ability. Contact Humana at 1-866-347-9507 to request expedited review with physician certification of urgency.

Does step therapy apply to Gattex in Texas? Humana typically requires documentation of failed attempts at enteral nutrition optimization and antimotility agents before approving Gattex, which functions as informal step therapy.

What happens if I miss the 65-day appeals deadline? You can still file an appeal, but you lose certain protections. Contact Humana immediately to discuss options and consider filing a complaint with the Texas Department of Insurance.

How much does Gattex cost with Humana coverage? Costs vary by plan, but Takeda offers copay assistance that may reduce out-of-pocket costs to $0-$10 for eligible patients. Check Takeda's patient assistance programs for current offerings.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. For additional assistance with insurance appeals in Texas, contact the Texas Department of Insurance consumer hotline at 1-800-252-3439.

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