By Counterforce Health Team in Hetlioz LQ (tasimelteon oral suspension) —

How to Get Hetlioz LQ Covered by Humana in Washington: Prior Authorization Forms, Appeals, and Coding Guide

Answer Box: Getting Hetlioz LQ Covered by Humana in Washington

Hetlioz LQ requires prior authorization from Humana with genetic confirmation of Smith-Magenis syndrome (ICD-10: Q93.5) and documented sleep disorder (G47.24). Submit PA requests via fax to 1-877-486-2621 with weight-based dosing calculations and specialist documentation. If denied, you have 65 days to appeal and can request external review through Washington's Independent Review Organization (IRO) process. First step today: Contact your prescriber to gather genetic test results and sleep study documentation for the PA submission.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Documentation Needed Timeline
Prior Authorization Required for all Hetlioz LQ Genetic test, sleep study, specialist notes 7 days for Part D decisions
Age Eligibility 3-15 years for Hetlioz LQ Birth certificate or medical records N/A
Diagnosis Smith-Magenis syndrome with sleep disorder ICD-10: Q93.5, G47.24 Must be current
Formulary Status Specialty tier, varies by plan Check Humana drug list Annual updates
Appeals Deadline 65 days from denial notice Written appeal with supporting docs IRO review within 7 days

Source: Humana Prior Authorization Guidelines

ICD-10 Coding for Smith-Magenis Syndrome

Primary diagnosis coding is crucial for Hetlioz LQ approval. Use these specific codes:

  • Q93.5: Deletion of short arm of chromosome 17 (Smith-Magenis syndrome)
  • G47.24: Circadian rhythm sleep disorder, free-running type
Clinician Note: Document the genetic confirmation (17p11.2 deletion or RAI1 mutation) in your clinical notes. Link the sleep disturbance directly to SMS genetics, as this strengthens medical necessity for circadian rhythm medications.

Documentation requirements include:

  • Genetic test results showing 17p11.2 deletion
  • Sleep pattern assessment (inverted melatonin rhythm)
  • Functional impact on daily activities
  • Failed conventional sleep interventions

The connection between SMS and circadian rhythm disorders is well-established in medical literature, with melatonin levels typically peaking during daytime hours rather than at night.

Product Coding and Billing

NDC and billing specifics for Hetlioz LQ:

  • NDC: 69336-0317-53 (oral suspension, 4 mg/mL)
  • No HCPCS J-code: Bill using NDC through pharmacy benefit
  • Coverage: Medicare Part D (not Part B)

Weight-based dosing calculations:

  • ≤28 kg: 0.7 mg/kg once daily
  • >28 kg: 20 mg (5 mL) once daily

Example calculation for 20 kg patient:

  • Dose: 0.7 mg/kg × 20 kg = 14 mg
  • Volume: 14 mg ÷ 4 mg/mL = 3.5 mL per dose
  • Monthly supply: 3.5 mL × 30 days = 105 mL
Billing Tip: Always include exact weight and calculated dose in mg and mL on the prescription. This helps justify the quantity requested and reduces PA delays.

Step-by-Step: Prior Authorization Process

1. Verify Coverage and Requirements

  • Check Humana's drug formulary for current tier placement
  • Contact Humana Clinical Pharmacy Review at 800-555-2546 for specific criteria

2. Gather Required Documentation

Clinical documentation checklist:

  • Genetic test confirming Smith-Magenis syndrome
  • Sleep disorder assessment with G47.24 diagnosis
  • Patient's current weight and age verification
  • Documentation of failed sleep hygiene interventions
  • Specialist (sleep medicine or genetics) consultation notes

3. Complete Prior Authorization Request

  • Submission method: Fax to 1-877-486-2621
  • Required forms: Use Humana's PA form (available through provider portal)
  • Include: All clinical documentation, dosing calculations, and NDC information

4. Track Your Request

  • Standard timeline: 7 days for Part D medication decisions
  • Expedited option: 72 hours if delay could jeopardize health
  • Follow up: Contact Humana if no response within stated timeframe

At Counterforce Health, we help patients and clinicians navigate complex prior authorization processes by turning denial letters into targeted, evidence-backed appeals. Our platform ingests denial documentation and drafts point-by-point rebuttals aligned to each plan's specific requirements.

Appeals Process in Washington

If Humana denies your Hetlioz LQ request, Washington state provides robust appeal rights:

Internal Appeals (First Level)

  • Deadline: 65 days from denial notice
  • Timeline: Humana must decide within 7 days (Part D)
  • Submission: Same fax number (1-877-486-2621) or member portal

External Review (IRO Process)

If internal appeal fails, your case automatically goes to an Independent Review Organization (IRO):

  • No cost to you: IRO review is free
  • Timeline: 7 days for standard review, 72 hours for expedited
  • Binding decision: If IRO approves, Humana must cover the medication

Washington State Resources

For additional help with appeals:

  • SHIBA Program: Free Medicare counseling at 1-800-562-6900
  • Washington Office of Insurance Commissioner: Consumer advocacy line for complex cases
  • External review requests: Can be submitted directly through Washington's IRO process
From Our Advocates: We've seen cases where initial PA denials were overturned simply by including the genetic test report that clearly showed the 17p11.2 deletion. Many denials occur because the connection between SMS and the need for circadian rhythm medication isn't clearly documented in the initial submission.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Provide genetic confirmation and sleep study Genetic test, sleep disorder diagnosis
"Age not appropriate" Confirm pediatric indication (3-15 years) Birth certificate, current medical records
"Insufficient documentation" Submit complete clinical picture All specialist notes, prior treatments tried
"Quantity exceeds limits" Show weight-based dosing calculation Patient weight, dosing formula, monthly calculation
"Step therapy not met" Document failed conventional treatments Sleep hygiene attempts, behavioral therapy records

Key strategy: Always link the sleep disturbance directly to the genetic diagnosis. SMS has a well-documented circadian rhythm disruption that conventional sleep aids don't address.

Cost and Support Options

Manufacturer support programs:

  • Vanda Pharmaceuticals offers patient assistance programs
  • Copay assistance may be available for commercially insured patients
  • Contact manufacturer directly for current program details

Washington state resources:

  • Apple Health (Medicaid) may cover for eligible families
  • Washington Healthplanfinder for insurance marketplace options
  • SHIBA counselors can help identify cost-saving opportunities

When to Contact Washington Regulators

Contact the Washington Office of Insurance Commissioner if:

  • Humana doesn't respond within required timeframes
  • You believe the denial was inappropriate
  • You need help understanding your appeal rights
  • The IRO process isn't working as expected

Contact information:

  • Consumer advocacy line: 1-800-562-6900
  • Online complaint filing available through OIC website
  • Free assistance with insurance disputes

Frequently Asked Questions

Q: How long does Humana's prior authorization take in Washington? A: Standard Part D medication decisions must be made within 7 calendar days. Expedited reviews are completed within 72 hours when delay could jeopardize health.

Q: What if Hetlioz LQ isn't on my Humana formulary? A: You can request a formulary exception with medical necessity documentation. This requires the same clinical evidence as a PA request plus justification for why formulary alternatives won't work.

Q: Can I get an expedited appeal if my child's sleep is severely disrupted? A: Yes, if the delay in treatment could seriously jeopardize your child's health, you can request expedited review at both internal appeal and IRO levels.

Q: Does step therapy apply to Hetlioz LQ for Smith-Magenis syndrome? A: Some plans may require documentation that conventional sleep interventions were tried first. Document any behavioral sleep strategies or other medications attempted.

Q: How much does Hetlioz LQ cost without insurance in Washington? A: Retail pricing frequently approaches $24,678 per bottle, making insurance coverage essential. Patient assistance programs may help reduce costs.

Q: What happens if the IRO denies my appeal? A: You can contact the Washington Office of Insurance Commissioner for guidance on additional options, including potential legal remedies.

Q: Can my pediatrician prescribe Hetlioz LQ, or do I need a specialist? A: While any licensed physician can prescribe it, many insurers prefer or require specialist consultation (sleep medicine, genetics, or neurology) for PA approval.

Q: How do I know if my child truly has Smith-Magenis syndrome? A: SMS requires genetic testing showing 17p11.2 deletion or RAI1 gene mutation. If you suspect SMS but lack genetic confirmation, consult a geneticist for proper testing.

For complex cases requiring detailed appeal strategies, Counterforce Health specializes in helping patients navigate insurance denials by creating targeted rebuttals based on each plan's specific requirements and pulling appropriate medical evidence to support coverage requests.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your insurer and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals in Washington, contact SHIBA at 1-800-562-6900.

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