By Counterforce Health Team in Givlaari (givosiran) —

How to Get Givlaari (givosiran) Covered by Humana in New York: Complete Appeals Guide with Forms and Scripts

Answer Box: Fast Track to Givlaari (givosiran) Coverage

Givlaari (givosiran) requires prior authorization for all Humana Medicare Advantage plans in New York. Submit via Humana's provider portal with attack history (≥2 in 6 months), elevated ALA/PBG labs, and specialist prescriber documentation. Standard decisions take 72 hours; expedited approvals in 24 hours for urgent cases. If denied, appeal within 65 days using Medicare's 5-level process—New York's external appeal system doesn't apply to Medicare plans. For commercial Humana plans, use New York's external review after internal appeals fail.

First step today: Contact your specialist to gather attack documentation and lab results, then submit PA request through Humana's provider portal or call 866-421-5663.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Forms and Submission Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process for New York
  6. Common Denial Reasons and Solutions
  7. Cost Assistance Programs
  8. FAQ
  9. Sources and Further Reading

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Required for all plans Standard PA form + clinical support Humana PA Lists
Attack History ≥2 documented attacks in past 6 months ER records, hemin use documentation Clinical evidence
Lab Confirmation Elevated urine ALA/PBG during symptoms Lab reports with reference ranges Medical charts
Specialist Prescriber Hematologist, hepatologist, or neurologist Provider credentials verification Humana Provider Directory
Diagnosis Confirmation Confirmed acute hepatic porphyria (AHP) Genetic testing or biochemical proof Clinical documentation

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan Type

Who: Patient
Action: Check your Humana ID card to confirm if you have Medicare Advantage, commercial insurance, or Medicaid managed care
Timeline: 5 minutes
Why it matters: Different plan types use different appeals processes in New York

2. Gather Required Documentation

Who: Patient + Healthcare Team
Documents needed:

  • Attack history records (ER visits, hospitalizations)
  • Laboratory results showing elevated ALA/PBG levels
  • Genetic testing results (if available)
  • Previous treatment records (hemin trials, trigger avoidance)
  • Current prescriber credentials verification

3. Submit Prior Authorization Request

Who: Prescribing specialist
Method: Humana Provider Portal or fax to 502-508-9300
Timeline: Submit immediately after documentation gathering
Phone support: 866-421-5663 (Mon-Fri 7am-7pm CT)

4. Request Expedited Review if Urgent

Who: Prescriber
When: If patient has active symptoms or recent attacks
Timeline: 24-hour decision for expedited requests
Documentation: Medical necessity letter emphasizing urgency

5. Follow Up on Decision

Who: Patient or provider
Timeline: Standard decisions within 72 hours
Action: Check provider portal or call member services for status updates

6. If Denied, File Appeal Immediately

Who: Patient (with provider support)
Timeline: Within 65 days of denial notice
Method: Depends on plan type (see Appeals Process section below)

7. Consider External Resources

Who: Patient
Resources: Community Health Advocates (888-614-5400) for free assistance
When: If internal appeals are unsuccessful

Forms and Submission Methods

Prior Authorization Forms

  • Primary form: Standard Humana prior authorization request form
  • Access: Available through Humana Provider Portal
  • Alternative submission: CoverMyMeds platform for electronic PA requests

Submission Channels

Electronic (Fastest):

  • Humana Provider Portal
  • CoverMyMeds integration
  • Availity network for providers

Fax:

  • Prior authorization: 502-508-9300
  • Appeals: 1-877-556-7005

Phone:

  • Clinical Pharmacy Review: 866-421-5663
  • Member Services: Number on back of insurance card

Mail (Slowest): Humana Prior Authorization
Clinical Pharmacy Services
P.O. Box 14546
Lexington, KY 40512-4546

Tip: Always request fax confirmation receipts and keep tracking numbers for mailed submissions.

Specialty Pharmacy Setup

CenterWell Specialty Pharmacy

Once Givlaari (givosiran) is approved, Humana typically requires use of their specialty pharmacy network:

Setup process:

  1. Prescription transfer to CenterWell Specialty Pharmacy
  2. Patient enrollment call (1-800-486-2668)
  3. Financial assistance screening
  4. Delivery coordination for monthly injections

Services included:

  • Clinical support with specialized nurses
  • Patient assistance program navigation
  • Home infusion coordination if needed
  • Adherence monitoring and support

Appeals Process for New York

For Humana Medicare Plans

Important: New York's external appeal system does NOT apply to Medicare plans. Use Medicare's 5-level appeals process:

Level 1 - Redetermination:

  • File within 65 days of denial
  • Contact: 1-800-451-4651
  • Timeline: 7 days standard, 72 hours expedited

Level 2 - Independent Review Entity:

  • Automatic if Level 1 denied
  • Timeline: 7 days standard, 72 hours expedited

Submission address: Humana Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4546

For Commercial Humana Plans

Use New York's external appeal system after internal appeals:

Internal Appeal First:

  • File with Humana within plan timelines
  • Gather denial letter and supporting documentation

External Appeal with NY DFS:

  • File within 4 months of final internal denial
  • Form: NY State External Appeal Application
  • Fee: $25 maximum (waived for financial hardship)
  • Timeline: 30 days standard, 72 hours expedited

NY DFS Contact:

  • Phone: 800-400-8882
  • Email: [email protected]
  • Mail: NY DFS, 99 Washington Avenue, Box 177, Albany, NY 12210

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient attack history Document all AHP episodes in past 12 months ER records, physician notes, hemin administration records
Missing lab confirmation Obtain ALA/PBG testing during symptomatic periods Lab reports with elevated levels and reference ranges
Non-specialist prescriber Transfer care to appropriate specialist Referral to hematologist, hepatologist, or neurologist
Continuation with hemin Demonstrate need for transition Medical necessity letter explaining hemin limitations
Lack of genetic confirmation Pursue genetic testing if biochemical proof insufficient Genetic counseling referral and testing results

Cost Assistance Programs

Manufacturer Support

Alnylam Assist Program:

  • Income-based assistance for eligible patients
  • Copay support for commercial insurance
  • Free drug program for uninsured patients
  • Contact: Visit alnylamassist.com or call program directly

Foundation Grants

Research foundations and rare disease organizations may provide grants for Givlaari (givosiran) treatment. Contact your specialist's office for current foundation grant opportunities.

State Programs

New York residents may qualify for additional assistance through state pharmaceutical assistance programs, particularly for Medicare beneficiaries.

Counterforce Health helps patients navigate insurance denials by creating targeted, evidence-backed appeals that align with each payer's specific requirements. The platform analyzes denial letters and plan policies to identify the exact coverage criteria, then generates comprehensive appeals with the clinical documentation and literature citations needed to overturn denials. For complex cases like Givlaari (givosiran) coverage, having expert appeal assistance can significantly improve approval odds and reduce the time to access treatment.

FAQ

How long does Humana prior authorization take for Givlaari (givosiran) in New York? Standard decisions take 72 hours, while expedited requests (for urgent medical needs) are decided within 24 hours. Your prescriber can request expedited review if you have active symptoms.

What if Givlaari (givosiran) is not on Humana's formulary? Request a formulary exception along with your prior authorization. Include documentation that no suitable formulary alternatives exist for your specific AHP subtype and attack pattern.

Can I use New York's external appeal system for Humana Medicare denials? No. Medicare plans must use the federal Medicare appeals process, not New York's state external appeal system. Start with a redetermination request to Humana within 65 days.

What counts as sufficient attack history for approval? Most policies require at least 2 documented AHP attacks in the past 6 months that required medical intervention, such as emergency department visits or hemin administration.

How much does Givlaari (givosiran) cost without insurance? The wholesale acquisition cost is approximately $41,375 per vial, with total annual costs varying based on patient weight (dosing is 2.5 mg/kg monthly).

What if my neurologist isn't considered a specialist for this medication? Neurologists are typically accepted as appropriate prescribers for Givlaari (givosiran). If questioned, provide documentation of the neurologist's experience treating acute hepatic porphyria patients.

Can I get help with my appeal in New York? Yes. Community Health Advocates offers free assistance at 888-614-5400. For Medicare plans, call 1-800-MEDICARE for guidance on the appeals process.

What happens if I miss the appeal deadline? Contact Humana immediately to discuss options. In some cases, good cause exceptions may be granted for late appeals, especially if you can document that you didn't receive proper notice.

From our advocates: "We've seen cases where patients initially received denials for insufficient attack documentation, but succeeded on appeal by working with their specialist to compile a comprehensive timeline of all AHP-related medical encounters over the past year, including subtle episodes that weren't initially recognized as attacks. The key was demonstrating the pattern and impact on quality of life, not just counting emergency department visits."

For additional support navigating complex insurance appeals, Counterforce Health specializes in turning denials into approvals through targeted, evidence-based appeal strategies tailored to each payer's specific requirements.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. Coverage policies and contact information may change; verify current details with official sources.

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