By Counterforce Health Team in Gilenya (fingolimod) —

How to Get Gilenya (fingolimod) Covered by Humana in Pennsylvania: Prior Authorization, Appeals & State Review Process

Answer Box: Getting Gilenya (fingolimod) Covered by Humana in Pennsylvania

Humana typically requires prior authorization for Gilenya (fingolimod), with the medication placed on Tier 4 (Specialty). To get coverage: (1) Your neurologist submits a PA request with baseline EKG, eye exam, vaccination records, and first-dose monitoring plan through Humana's provider portal, (2) If denied, file an internal appeal within 65 days, then (3) Request Pennsylvania's state external review within 4 months of your final denial—this new process overturns about 50% of denials. Start by calling Humana Member Services to confirm your plan's specific formulary status and PA requirements.

Table of Contents

What Drives Gilenya (fingolimod) Costs with Humana

Understanding why Gilenya (fingolimod) can be expensive under Humana helps you navigate the approval process more effectively. The medication's cost is influenced by several benefit design factors:

Formulary Tier Placement: Humana typically places brand Gilenya on Tier 4 (Specialty), which involves higher copays or coinsurance compared to generic alternatives. Generic fingolimod may be placed in Tier 3 or 4 depending on your specific plan. You can check your exact tier placement by logging into your MyHumana account or reviewing your plan's formulary.

Prior Authorization Requirements: Both brand and generic fingolimod require prior authorization under most 2024 Humana Medicare Advantage plans. This means your doctor must demonstrate medical necessity before coverage begins.

Step Therapy: Humana usually requires you to try other first-line MS treatments (such as interferons, glatiramer acetate, or dimethyl fumarate) before approving fingolimod, unless there's documented intolerance or contraindications.

Specialty Drug Designation: As a specialty medication, Gilenya must be dispensed through Humana's designated specialty pharmacy network, typically CenterWell Specialty Pharmacy, with a maximum 30-day supply per fill.

Investigating Your Benefits: Key Questions to Ask

Before starting the approval process, gather essential information about your specific Humana plan. Call Humana Member Services and ask:

  1. "What tier is Gilenya (fingolimod) on my formulary, and what's my copay or coinsurance?"
  2. "Does my plan require prior authorization for Gilenya (fingolimod)?"
  3. "Are there step therapy requirements I need to meet first?"
  4. "Which specialty pharmacy should my doctor send the prescription to?"
  5. "What's the maximum days supply allowed per fill?"
Tip: Record the representative's name, date, and reference number for your call. This documentation can be helpful if you need to appeal later.

Keep detailed records of:

  • Your insurance card and member ID
  • Previous MS medications tried and outcomes
  • Current neurologist's contact information
  • Any denial letters or explanations of benefits (EOBs)

Assistance Options: Copay Cards and Foundations

Commercial Copay Programs (Not for Medicare)

If you have commercial insurance through an employer rather than Medicare, you may be eligible for Novartis's Gilenya copay assistance program, potentially reducing your out-of-pocket costs to as little as $0 per month. However, Medicare beneficiaries are not eligible for these commercial copay cards due to federal anti-kickback regulations.

Novartis Patient Assistance Foundation (NPAF)

Medicare patients may qualify for free Gilenya through the Novartis Patient Assistance Foundation if their household income meets strict limits. For 2024, the income limit for a two-person household is $81,760 or less. You'll need to provide tax returns and reapply annually.

Third-Party Foundations

Organizations like The Assistance Fund or other patient advocacy groups sometimes offer grants for specialty medications, though funding availability varies and programs may have waiting lists.

Counterforce Health helps patients navigate these complex assistance programs by analyzing denial letters and identifying the most effective appeal strategies, including connecting patients with appropriate financial assistance resources based on their specific insurance situation.

Requesting Tier Exceptions and Medical Necessity

If Gilenya (fingolimod) is on a high-cost tier or not covered, you can request a tier exception or medical necessity determination. Your neurologist must submit detailed documentation including:

Required Documentation Checklist

  • Confirmed MS diagnosis with ICD-10 code G35 and clinical notes from a neurologist
  • Baseline EKG results (not just ordered—actual results attached)
  • Ophthalmologic examination within the last 12 months due to macular edema risk
  • Vaccination status, especially varicella zoster immunity or vaccination records
  • First-dose cardiac monitoring plan detailing the 6-hour observation protocol
  • Prior therapy documentation specifying which MS drugs were tried, clinical outcomes, and reasons for discontinuation
  • Medical necessity letter explaining why lower-tier alternatives are inappropriate or ineffective

Submission Process

Your neurologist should submit all documentation through Humana's provider portal with complete supporting materials attached (not just referenced). Humana typically makes decisions within 72 hours for standard requests, with expedited options available for urgent cases.

Clinician Corner: When writing the medical necessity letter, be specific about clinical outcomes from previous therapies. Instead of "patient failed interferon," write "patient experienced 3 relapses over 8 months on interferon beta-1a despite good adherence, with EDSS progression from 2.0 to 3.5."

Specialty Pharmacy Requirements

Humana requires that Gilenya (fingolimod) be dispensed only through designated specialty pharmacies, typically CenterWell Specialty Pharmacy. Key requirements include:

  • 30-day supply maximum per fill (no 90-day supplies allowed)
  • No splitting between retail and mail order within the same fill cycle
  • Prior authorization must be completed before the specialty pharmacy can dispense
  • Registration required with CenterWell through MyHumana or by phone

Your neurologist should send new prescriptions directly to CenterWell using official forms provided by Humana and CenterWell.

Appeals Process: Internal and Pennsylvania External Review

Internal Appeals with Humana

If your initial prior authorization is denied, you have 65 days from the denial date to file an internal appeal with Humana. Submit:

  • The original denial letter
  • Additional clinical documentation
  • Updated medical necessity letter from your neurologist
  • Any new test results or clinical notes

Pennsylvania's External Review Process

Pennsylvania launched a new state-supervised external review program in January 2024 that's been highly successful for patients. Here's how it works:

Eligibility: Available for commercial health insurance policies (including those purchased through Pennie or employer plans), but not self-funded employee plans.

Timeline:

  1. Complete internal appeals first and receive a Final Adverse Benefit Determination
  2. Submit external review request within 4 months via Pennsylvania's online portal
  3. PID eligibility determination within 5 business days
  4. Submit additional documentation within 15 business days if approved
  5. Final decision within 45 calendar days from assignment

Success Rate: Approximately 50% of external reviews are decided in favor of patients, forcing insurers to provide coverage they initially denied.

The external review decision is final and binding on Humana. If you win, the insurer must cover your medication immediately, including retroactively if you paid out-of-pocket during the appeal.

Planning for Annual Renewals

Humana can change formulary tiers, prior authorization requirements, and covered medications annually. To prepare:

  • Review your Annual Notice of Change (sent by October 31st each year)
  • Check if Gilenya (fingolimod) remains on formulary and at the same tier
  • Confirm your specialty pharmacy is still in-network
  • Update any expired clinical documentation (EKGs, eye exams) before your plan year begins

Counterforce Health can help you analyze these annual changes and proactively address any new coverage barriers before they impact your treatment.

Conversation Scripts

Calling Humana Member Services

"Hi, I'm a Humana member calling about coverage for Gilenya, also known as fingolimod, for multiple sclerosis. My member ID is [ID number]. Can you tell me what tier this medication is on my formulary and whether prior authorization is required? I'd also like to know which specialty pharmacy I should use and what my estimated copay would be."

Requesting Peer-to-Peer Review

"This is [Doctor's name] calling to request a peer-to-peer review for my patient's Gilenya prior authorization denial. The patient has relapsing MS with documented progression on first-line therapies, and I have clinical justification for why fingolimod is medically necessary. When can we schedule this review?"

FAQ

How long does Humana prior authorization take in Pennsylvania? Standard PA decisions typically take 72 hours from submission of complete documentation. Expedited requests for urgent cases are handled within 24 hours.

What if Gilenya (fingolimod) is not on my formulary at all? You can request a formulary exception with detailed medical rationale explaining why covered alternatives aren't suitable for your specific case.

Can I request an expedited appeal in Pennsylvania? Yes, both Humana's internal appeals and Pennsylvania's external review process offer expedited options for urgent health situations.

Does step therapy apply if I've already tried other MS medications outside Pennsylvania? Yes, previous therapy trials from other states count toward step therapy requirements, as long as you have proper documentation of the trials and outcomes.

What happens if I move to Pennsylvania from another state while on Gilenya? Contact Humana immediately to confirm coverage continuity. You may be eligible for a transition supply while your new PA is processed.

How much does Gilenya (fingolimod) cost without insurance? Brand Gilenya cash prices often exceed $10,000 per month, while generic fingolimod is significantly less expensive but still costly.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For personalized help with insurance appeals and prior authorization strategies, consider consulting with patient advocacy services or organizations like Counterforce Health that specialize in turning insurance denials into successful appeals.

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