By Counterforce Health Team in Gattex (teduglutide) —

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

Answer Box: Getting Gattex (Teduglutide) Covered by Humana in Washington

Humana requires prior authorization (PA) for Gattex (teduglutide) for short bowel syndrome with parenteral nutrition dependence. Your gastroenterologist submits PA electronically via Humana's provider portal with documented SBS diagnosis, 12+ months of PN logs, recent colonoscopy, and failed enteral nutrition attempts. Standard decisions take 72 hours; denials can be appealed internally within 65 days, then through Washington's Independent Review Organization (IRO) process. First step today: Call Humana at 800-867-6601 to confirm your plan's formulary status and PA requirements.

Table of Contents

  1. Coverage Basics: Is Gattex Covered by Humana?
  2. Prior Authorization Process: Who Submits and How
  3. Timing: How Long Does Approval Take?
  4. Medical Necessity Criteria: What Humana Requires
  5. Cost Considerations: What You'll Pay
  6. Denials and Appeals: Your Rights in Washington
  7. Renewal Requirements: Staying Covered
  8. Specialty Pharmacy: Where to Get Gattex
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics: Is Gattex Covered by Humana?

Humana covers Gattex (teduglutide) as a specialty drug under Part D pharmacy benefits for Medicare Advantage plans and under prescription drug benefits for commercial plans. However, coverage requires prior authorization in virtually all cases.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Yes, required for SBS indication Humana PA Search Tool
Formulary Status Specialty tier (varies by plan) Member ID card or call 800-867-6601
Age Restrictions FDA-approved for ages 1+ FDA Label
Diagnosis Codes K90.82, K90.821, K90.822 (SBS) ICD-10 requirements
Prescriber Requirements Gastroenterologist or specialist Humana policy
Note: Self-funded employer plans may have different requirements. Check your specific plan documents or call the number on your insurance card.

Prior Authorization Process: Who Submits and How

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic)
    • Call Humana at 800-867-6601 with member ID
    • Confirm Gattex is on formulary and PA requirements
    • Timeline: 5-10 minutes
  2. Gather Required Documentation (Clinic)
    • SBS diagnosis with ICD-10 code
    • 12+ months of parenteral nutrition logs
    • Recent colonoscopy report (within 6 months)
    • Failed enteral nutrition attempts
    • Timeline: 1-2 business days
  3. Complete REMS Program (Prescriber)
    • Register at gattexrems.com
    • Complete knowledge assessment
    • Timeline: 30-60 minutes
  4. Submit Electronic PA (Prescriber)
    • Use Humana provider portal (preferred)
    • Include medical necessity letter and all supporting documents
    • Timeline: 15-30 minutes to submit
  5. Track Decision (Clinic/Patient)
    • Monitor portal for status updates
    • Standard decision within 72 hours
    • Timeline: 1-3 business days

Required Documentation Checklist

  • Medical necessity letter from gastroenterologist
  • SBS diagnosis confirmation with remaining bowel length
  • Parenteral nutrition logs (volume, frequency, duration)
  • Colonoscopy report with polyp removal if applicable
  • Documentation of failed enteral nutrition optimization
  • Recent labs (liver function, electrolytes)
  • Patient demographics and insurance information

Timing: How Long Does Approval Take?

Standard Timeline

  • Electronic PA submission: 72 hours for decision
  • Paper/fax submission: Up to 15 business days
  • Expedited review: 24-72 hours if urgent medical need

When to Request Expedited Review

  • Severe malnutrition requiring immediate intervention
  • Parenteral nutrition complications (line infections, liver dysfunction)
  • Hospitalization risk due to intestinal failure
Tip: Humana prioritizes electronic submissions and aims for 1-business-day decisions by 2026 for complete ePA requests.

Medical Necessity Criteria: What Humana Requires

Humana's coverage policy requires documentation of all the following criteria:

Primary Requirements

  1. Confirmed SBS Diagnosis
    • Short bowel syndrome with intestinal failure
    • Remaining small bowel length <200 cm (when documented)
    • ICD-10 code K90.82, K90.821, or K90.822
  2. Parenteral Nutrition Dependence
    • ≥3 days per week for ≥12 months
    • Detailed logs showing volume, calories, and duration
    • Evidence of PN complications or quality of life impact
  3. Failed Conservative Management
    • Optimized enteral nutrition attempts
    • Antidiarrheal medications (loperamide, diphenoxylate)
    • Antisecretory agents (proton pump inhibitors)
    • Dietary modifications and nutrition counseling
  4. Safety Screening
    • Colonoscopy within 6 months (adults)
    • Fecal occult blood test (pediatric patients)
    • Baseline liver function tests
    • No active GI malignancy

Clinician Corner: Medical Necessity Letter Template

Your medical necessity letter should include:

Patient Information

  • Name, DOB, insurance ID, diagnosis codes
  • SBS etiology (surgical resection, congenital, etc.)
  • Remaining anatomy (bowel length, colon presence)

Clinical History

  • Duration and details of PN dependence
  • Previous attempts at PN weaning
  • Complications from current management

Prior Therapies

  • Specific enteral nutrition formulas tried
  • Medications used (doses and duration)
  • Dietary interventions and outcomes

Treatment Goals

  • Expected PN reduction targets
  • Monitoring plan and safety assessments
  • Quality of life improvements anticipated

For evidence-based appeal support and template letters, Counterforce Health helps patients and clinicians turn insurance denials into targeted, successful appeals by analyzing denial letters and crafting point-by-point rebuttals aligned with plan policies.

Cost Considerations: What You'll Pay

Insurance Coverage

  • Specialty tier copay: Typically $50-$150 per month for Medicare Part D
  • Commercial plans: Varies by deductible and coinsurance structure
  • Out-of-pocket maximum: Medicare Part D catastrophic coverage applies

Financial Assistance Options

  • Takeda Patient Support: Copay assistance and free drug programs
  • State pharmaceutical assistance: Washington State Apple Health may cover for eligible patients
  • Foundation grants: Patient Access Network Foundation and similar organizations
Note: Gattex wholesale cost is approximately $46,893 per 30-vial kit, making insurance coverage essential.

Denials and Appeals: Your Rights in Washington

Common Denial Reasons and Solutions

Denial Reason How to Address Required Evidence
Insufficient PN documentation Provide detailed logs Volume, frequency, complications over 12+ months
Missing safety screening Submit colonoscopy report Results within 6 months, polyp removal if needed
Inadequate prior therapies Document optimization attempts Specific medications, doses, durations, outcomes
Non-formulary status Request formulary exception Medical necessity for Gattex vs. alternatives

Washington State Appeals Process

Internal Appeals (Required First Step)

  1. Submit appeal within 65 days of denial
  2. Include additional clinical evidence addressing denial reasons
  3. Request peer-to-peer review with Humana medical director
  4. Decision within 30 days (expedited: 72 hours)

External Review (Washington IRO Process) If internal appeals fail, Washington residents can request independent review:

  1. File Request: Within 180 days of final internal denial
  2. Submit to: Humana (who forwards to Washington Office of Insurance Commissioner)
  3. IRO Assignment: Independent Review Organization assigned within 3 business days
  4. Decision Timeline: 30 days standard, 72 hours expedited
  5. Outcome: Binding decision on insurer if overturned

Washington Office of Insurance Commissioner Resources

  • Consumer Advocacy: 1-800-562-6900
  • Online Appeals Guide: insurance.wa.gov
  • IRO Process Information: Available on OIC website
From our advocates: "We've seen Washington's external review process successfully overturn Humana denials for specialty medications when patients provided comprehensive clinical documentation. The key is addressing each specific denial reason with evidence-based responses and utilizing the state's robust consumer protection framework."

Renewal Requirements: Staying Covered

Humana typically approves Gattex for 6-12 month periods with renewal requirements:

When to Submit Renewal

  • 30-45 days before expiration to avoid coverage gaps
  • Track authorization end date in member portal

Renewal Documentation

  • Updated PN logs showing reduction or clinical benefit
  • Weight trends and nutritional status
  • Adherence confirmation and tolerance assessment
  • Updated colonoscopy if due per monitoring schedule
  • Continued medical necessity justification

Success Metrics Humana Looks For

  • ≥20% reduction in PN volume or frequency
  • Weight stabilization or gain
  • Fewer hospitalizations or line complications
  • Improved quality of life measures

Specialty Pharmacy: Where to Get Gattex

Humana's Specialty Network

Gattex must be dispensed through Humana's specialty pharmacy network:

  • Primary: CenterWell Specialty Pharmacy
  • Phone: 844-486-2668
  • Services: Home delivery, clinical support, insurance coordination

Patient Enrollment Process

  1. PA Approval: Must be obtained before specialty pharmacy enrollment
  2. Prescription Transfer: CenterWell contacts your current pharmacy
  3. Delivery Setup: Home delivery scheduling and injection training
  4. Ongoing Support: Refill reminders and clinical monitoring
Tip: Contact CenterWell immediately after PA approval to expedite the enrollment process and avoid delays in starting therapy.

Troubleshooting Common Issues

Portal and System Problems

  • Humana provider portal down: Call 1-800-448-6262 for technical support
  • Missing forms: Download from provider.humana.com or request via phone
  • ePA system errors: Submit via fax as backup: (verify current fax number with Humana)

Documentation Issues

  • Missing colonoscopy: Schedule urgent screening if within 6 months of request
  • Incomplete PN logs: Work with nutrition team to reconstruct detailed records
  • Prescriber specialty: Ensure gastroenterologist involvement in care

Communication Breakdowns

  • Patient-provider coordination: Use secure messaging systems for updates
  • Insurance verification: Always confirm current benefits before submission
  • Appeal deadlines: Set calendar reminders for all critical dates

Frequently Asked Questions

Q: How long does Humana prior authorization take for Gattex in Washington? A: Standard electronic PA decisions are made within 72 hours. Expedited reviews for urgent cases can be completed within 24-72 hours.

Q: What if Gattex is non-formulary on my Humana plan? A: You can request a formulary exception by demonstrating medical necessity and lack of suitable formulary alternatives. This requires additional documentation but follows the same PA process.

Q: Can I request an expedited appeal in Washington? A: Yes, if standard timelines could seriously jeopardize your health. Both Humana internal appeals and Washington's IRO process offer expedited options.

Q: Does step therapy apply if I've tried similar medications outside Washington? A: Prior therapy documentation from any location is typically accepted. Provide complete records of previous treatments and outcomes.

Q: What happens if Humana denies my appeal? A: Washington residents can request external review through an Independent Review Organization (IRO). This provides an independent medical review that's binding on Humana if overturned.

Q: How much will Gattex cost with Humana coverage? A: Costs vary by plan type. Medicare Part D typically has specialty tier copays of $50-$150 monthly. Commercial plans vary based on deductibles and coinsurance.

Q: Can my primary care doctor prescribe Gattex? A: While technically possible, Humana typically requires gastroenterology or specialist involvement for PA approval, given the complexity of SBS management.

Q: What if I move from Washington to another state? A: Your Humana coverage continues, but state-specific appeal rights may change. Contact Humana and your new state's insurance commissioner for guidance.

Glossary

Prior Authorization (PA): Insurance requirement to approve coverage before dispensing medication Formulary: List of covered medications by insurance plan Step Therapy: Requirement to try less expensive alternatives first Medical Necessity: Clinical justification that treatment is appropriate and required IRO: Independent Review Organization that provides external appeals review REMS: Risk Evaluation and Mitigation Strategy required by FDA for certain medications

Important: This guide provides general information and should not replace professional medical advice. Insurance policies and requirements may change. Always verify current information with Humana and consult your healthcare provider for medical decisions.

For personalized assistance with Gattex prior authorization or appeals, Counterforce Health provides specialized support in turning insurance denials into successful approvals through evidence-based appeal strategies tailored to each insurer's specific requirements.

Sources & Further Reading

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