By Counterforce Health Team in Hetlioz (tasimelteon) —

How to Get Hetlioz (Tasimelteon) Approved by Humana in Ohio: Complete PA Guide and Appeal Process

Quick Answer: Getting Hetlioz Covered by Humana in Ohio

Hetlioz (tasimelteon) is covered by Humana Ohio plans but requires prior authorization on specialty tiers. The fastest path: Have your sleep specialist or neurologist complete Humana's PA form with genetic testing (for SMS) or blindness documentation (for Non-24), proof of melatonin trial failure, and ICD-10 code G47.24. Submit through Humana's provider portal or CenterWell Specialty Pharmacy. Standard decisions take 72 hours; expedited reviews 24 hours. If denied, you have 65 days to appeal internally, then 180 days for Ohio external review through the Department of Insurance.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You Need to Provide More Information
  7. If Your Request is Denied
  8. Renewal and Re-Authorization
  9. Quick Reference Checklist

What This Guide Covers

This guide helps Ohio residents get Hetlioz (tasimelteon) approved by Humana, whether you have Medicare Advantage, Part D, or commercial coverage. Hetlioz is FDA-approved for two specific conditions: Non-24-hour sleep-wake disorder in totally blind adults, and nighttime sleep disturbances in Smith-Magenis syndrome (SMS).

At typical retail prices of around $5,895 for 30 capsules, prior authorization is mandatory for all Humana plans. The good news: Humana has one of the lowest denial rates among major insurers at approximately 3.5% for Medicare Advantage, and their specialty pharmacy network streamlines the process.

Who this helps: Patients with Non-24 or SMS, their caregivers, and healthcare providers navigating Humana's requirements in Ohio.

Before You Start: Verify Your Coverage

Check Your Plan Type and Formulary Status

First, confirm Hetlioz is covered on your specific Humana plan:

Hetlioz typically appears on specialty tiers (Tier 5 or 6), meaning higher copays but confirmed coverage once approved.

Confirm Pharmacy Network Requirements

Hetlioz must be dispensed through Humana's specialty pharmacy network, primarily CenterWell Specialty Pharmacy. Contact them at 1-800-486-2668 (Monday-Friday 8 AM-11 PM, Saturday 8 AM-6:30 PM Eastern) to verify network status and coordinate delivery.

Gather Required Documentation

Essential Clinical Documentation

Your prescriber needs comprehensive documentation to support medical necessity:

For Non-24-Hour Sleep-Wake Disorder:

  • Chart notes confirming total blindness (cannot perceive light)
  • ICD-10 code: G47.24 (Circadian rhythm sleep disorder, free running type)
  • Sleep study results or detailed sleep logs showing circadian misalignment
  • Documentation of functional impairment from sleep disruption

For Smith-Magenis Syndrome:

  • Genetic test results showing heterozygous 17p11.2 deletion or RAI1 mutation
  • ICD-10 codes: G47.24 (primary) and Q93.82 (SMS, secondary)
  • Sleep disorder assessment specific to SMS
  • Age verification (capsules for 16+, oral suspension for ages 3-15)

Step Therapy Documentation

Humana requires documented trial and failure of melatonin before approving Hetlioz:

  • Melatonin trial duration: Minimum 6 months of continuous use
  • Dosing details: Appropriate therapeutic doses attempted
  • Outcome documentation: Lack of efficacy, intolerance, or contraindications
  • Alternative attempts: Any trials of ramelteon or other sleep aids

Specialist Requirements

The prescription and PA must be completed by or in consultation with:

  • Sleep specialist
  • Neurologist
  • Psychiatrist
  • Geneticist (for SMS cases)

Submit Your Prior Authorization Request

Humana PA Process

  1. Provider Portal Submission: Your doctor submits the PA through Humana's provider portal
  2. Required Forms: Complete Humana's specific PA form for Hetlioz (available on provider portal)
  3. Fax Option: Submit to Humana's PA department at 1-877-486-2621 (verify current number from your form)
  4. Specialty Pharmacy Coordination: CenterWell Specialty Pharmacy may assist with PA submission and fulfillment

Clean Request Packet Checklist

Ensure your provider includes:

  • Completed PA form with all fields filled
  • Prescriber attestation of medical necessity
  • Genetic testing results (SMS) or blindness documentation (Non-24)
  • Melatonin trial history with dates, doses, and outcomes
  • Sleep study or detailed sleep assessment
  • ICD-10 diagnosis codes
  • Patient age verification
  • Contraindications to alternatives (if applicable)

Follow-Up and Timelines

Standard Processing Times

  • Standard PA requests: 72 hours for decision
  • Expedited requests: 24 hours (requires medical urgency documentation)
  • Medicare Part D appeals: 7 days standard, 72 hours expedited

When to Follow Up

Call Humana member services if you haven't heard back within:

  • 3 business days for standard requests
  • 1 business day for expedited requests

Sample follow-up script: "I'm calling about prior authorization request #[reference number] for Hetlioz submitted on [date]. Can you provide a status update and expected decision timeline?"

Always document:

  • Call date and time
  • Representative name
  • Reference numbers
  • Next steps provided

If You Need to Provide More Information

Common Medical Necessity Questions

Humana may request additional documentation for:

Clinical Justification:

  • More detailed sleep assessment data
  • Functional impact measurements
  • Treatment goals and monitoring plan
  • Literature supporting off-label use (if applicable)

Prior Therapy Documentation:

  • Complete medication history with dates
  • Specific reasons for discontinuation
  • Side effects or contraindications experienced

Supporting Literature

Include peer-reviewed references when relevant:

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Insufficient diagnosis documentation Submit genetic testing or blindness certification
Step therapy not met Provide detailed melatonin trial records
Age/indication mismatch Verify FDA labeling for patient's age and condition
Not medically necessary Submit functional assessment and treatment goals
Non-formulary status Request formulary exception with medical necessity

Humana Appeals Process in Ohio

Level 1: Internal Appeal

  • Deadline: 65 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • How to submit: Humana appeals portal or written request

Level 2: External Review (Ohio)

  • Deadline: 180 days from final internal denial
  • Process: File with Humana, who notifies Ohio Department of Insurance
  • Timeline: 30 days for decision, 72 hours for expedited
  • Contact: Ohio Department of Insurance at 1-800-686-1526
From our advocates: We've seen Hetlioz appeals succeed when providers include comprehensive sleep logs showing the specific circadian pattern disruption, alongside genetic confirmation for SMS cases. The key is demonstrating that standard melatonin therapy specifically failed to address the underlying circadian rhythm disorder, not just general sleep issues.

Peer-to-Peer Review Option

Request a peer-to-peer review where your prescribing physician speaks directly with Humana's medical director:

  • Usually available within 1-2 business days of request
  • Allows real-time clarification of clinical rationale
  • Often resolves complex cases faster than written appeals

Renewal and Re-Authorization

When to Start Renewal Process

Begin renewal 30-60 days before your current authorization expires. Humana typically requires annual reauthorization for Hetlioz.

Renewal Documentation Requirements

  • Evidence of treatment response and sleep improvement
  • Continued medical necessity
  • Updated sleep assessments
  • Confirmation that alternatives remain inappropriate
  • Any changes in diagnosis or treatment goals

Tracking Your Authorization

Keep a calendar reminder system:

  • Note original approval date and duration
  • Set renewal reminder 60 days before expiration
  • Track any quantity limit resets or changes

Quick Reference Checklist

Before Starting:

  • Verify Hetlioz is on your Humana formulary
  • Confirm CenterWell Specialty Pharmacy network status
  • Identify qualified prescribing specialist

Documentation Needed:

  • ICD-10 code G47.24 documented
  • Genetic testing (SMS) or blindness certification (Non-24)
  • 6-month melatonin trial failure documentation
  • Sleep study or comprehensive assessment
  • Specialist evaluation and prescription

Submission Process:

  • Complete Humana PA form through provider portal
  • Include all supporting clinical documentation
  • Coordinate with CenterWell Specialty Pharmacy
  • Track reference numbers and timelines

If Denied:

  • File internal appeal within 65 days
  • Consider peer-to-peer review option
  • Prepare for Ohio external review if needed
  • Contact Ohio Department of Insurance: 1-800-686-1526

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses that align with each payer's specific requirements. Their platform helps patients and providers navigate complex prior authorization processes like Humana's Hetlioz approval pathway, ensuring all necessary documentation and clinical evidence is properly presented to maximize approval chances.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For additional help with Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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