By Counterforce Health Team in Hetlioz (tasimelteon) —

How to Get Hetlioz (Tasimelteon) Covered by Humana in Florida: Prior Authorization Forms, Appeals Process, and Medical Necessity Requirements

Quick Answer: Hetlioz (tasimelteon) requires prior authorization from Humana Medicare plans in Florida. Submit PA request through CenterWell Specialty Pharmacy with documented Non-24-Hour Sleep-Wake Disorder diagnosis, sleep logs, and failed conservative therapies. Standard approval takes 7-30 days; expedited review available if delay risks health. Appeals must be filed within 65 days of denial. Start by calling Humana Member Services at the number on your ID card to confirm formulary status and request PA forms.

Table of Contents

Coverage Basics

Is Hetlioz (Tasimelteon) Covered by Humana in Florida?

Hetlioz (tasimelteon) is typically covered under Humana Medicare Part D plans as a specialty tier medication, but requires prior authorization for all indications. The drug treats Non-24-Hour Sleep-Wake Disorder in adults and nighttime sleep disturbances in Smith-Magenis syndrome.

Coverage at a Glance:

Requirement Details Where to Find
Prior Authorization Required for all plans Humana Provider Portal
Formulary Tier Specialty (Tier 5) Plan's Prescription Drug Guide
Specialty Pharmacy CenterWell required Humana Specialty Pharmacy
Age Restrictions Adults for N24SWD; 3+ for SMS FDA labeling
Diagnosis Codes ICD-10 required Provider documentation

Which Humana Plans Cover Hetlioz?

Most Humana Medicare Advantage and Part D plans in Florida include Hetlioz on their formularies, including:

  • Humana Value Rx (PDP)
  • Humana Medicare Advantage plans
  • Humana Dual-Eligible Special Needs Plans

Check your specific plan's Prescription Drug Guide or use the Humana drug search tool with your Florida ZIP code.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient): Call Humana Member Services at the number on your ID card or 1-800-281-6918 to confirm Hetlioz is on your plan's formulary.
  2. Gather Documentation (Prescriber): Collect sleep logs (2-4 weeks), actigraphy data, prior treatment records, and genetic testing results if applicable for Smith-Magenis syndrome.
  3. Submit PA Request (Prescriber): Complete Humana's prior authorization form via the provider portal or fax to the number on the form.
  4. Route to Specialty Pharmacy (Patient/Prescriber): Send prescription to CenterWell Specialty Pharmacy at 1-800-486-2668.
  5. Track Status (Patient): Monitor approval through MyHumana portal or by calling Member Services with your confirmation number.
  6. Receive Medication (Patient): CenterWell will coordinate delivery and provide clinical support once approved.

Who Submits the Prior Authorization?

Your prescribing physician or their office staff submits the PA request. Patients cannot submit directly, but you can:

  • Request your doctor's office check the status
  • Provide additional documentation if requested
  • Call Humana to verify receipt of the submission

Medical Necessity Requirements

Documentation for Non-24-Hour Sleep-Wake Disorder

ICSD-3 diagnostic criteria require documentation of:

Core Requirements:

  • Chronic irregular sleep-wake episodes across 24 hours
  • Insomnia at scheduled sleep times and/or excessive daytime sleepiness
  • Symptoms persisting ≥3 months
  • Progressive delay of sleep onset/offset (1-2 hours daily)

Required Diagnostic Tools:

  • Sleep diary: Daily logs showing progressive delay pattern over 2-4 weeks
  • Actigraphy: Wrist device tracking movement-based sleep-wake patterns
  • Clinical questionnaires: Pittsburgh Sleep Quality Index (PSQI) score >5
  • Medical history: Vision status, neurological conditions, prior treatments

Smith-Magenis Syndrome Documentation

For SMS patients, include:

  • Genetic testing confirming 17p11.2 deletion or RAI1 mutation
  • Documentation of circadian rhythm disruption (inverse melatonin pattern)
  • Evidence that N24SWD affects 80-90% of SMS patients
Clinician Corner: Medical necessity letters should reference AASM ICSD-3 criteria, include specific sleep diary data showing non-24-hour patterns, document failed conservative therapies (light therapy, sleep hygiene), and cite FDA labeling for the specific indication being treated.

Timing and Deadlines

How Long Does Prior Authorization Take?

Standard Timeline:

  • Part D medications: 7-30 days for standard review
  • Expedited review: 72 hours if delay could harm health
  • Reauthorization: Typically required annually

When to Request Expedited Review

Request expedited processing if:

  • Standard timeline could seriously harm health or function
  • Patient is experiencing severe sleep disruption affecting daily activities
  • Current treatment has failed and immediate alternative is needed

Submit expedited requests by calling Humana Member Services at 800-867-6601 and clearly stating the urgent medical need.

Costs and Specialty Pharmacy

What Will Hetlioz Cost?

Hetlioz pricing varies by plan, but typical costs include:

  • Retail pricing: ~$5,895 for 30×20mg capsules; ~$24,678 for Hetlioz LQ
  • Insurance coverage: Specialty tier copay/coinsurance applies
  • Out-of-pocket maximum: $2,100 cap for Medicare Part D in 2026

Why Specialty Pharmacy is Required

CenterWell Specialty Pharmacy is Humana's preferred network for specialty medications because they provide:

  • Temperature-controlled shipping and handling
  • Clinical support and medication counseling
  • Financial assistance program enrollment
  • Coordination with prescribers for monitoring

Contact CenterWell: 1-800-486-2668 (Mon-Fri 8am-11pm ET, Sat 8am-6:30pm ET)

Appeals Process in Florida

When dealing with prescription drug coverage challenges, Counterforce Health helps patients and clinicians transform insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with the insurer's own rules, significantly improving approval rates for specialty medications like Hetlioz.

Humana Medicare Appeals Timeline

Filing Deadlines:

  • Part D appeals: 65 days from denial notice
  • Internal appeal decision: 7 calendar days
  • Expedited appeals: 72 hours if urgent

How to File:

  1. Internal Appeal: Submit Part D Coverage Determination form via portal, mail, or fax
  2. Independent Review: If denied, escalate to Independent Review Entity within 65 days
  3. External Review: Contact Florida Department of Financial Services if needed

Florida-Specific Appeal Rights

Florida residents have additional protections under state law:

  • Internal appeals: 180 days to file (federal standard)
  • External review: 4 months after final denial
  • Consumer assistance: Florida Division of Consumer Services at 1-877-693-5236

External Review Process: Contact the Florida Department of Financial Services for independent medical review if Humana upholds the denial. This service is free and binding on the insurer if overturned.

Common Denial Reasons

Denial Reason How to Overturn Documentation Needed
Diagnosis not documented Submit ICSD-3 criteria checklist Sleep diary, actigraphy, clinical notes
Step therapy required Request exception for medical necessity Prior treatment failure documentation
Non-formulary status File formulary exception Prescriber letter explaining medical need
Quantity limits exceeded Document medical necessity for dosing FDA labeling, prescriber justification
Age restrictions Provide diagnosis confirmation Genetic testing (SMS), clinical evaluation

Scripts for Common Situations

Patient calling Humana about PA status: "Hi, I'm calling to check the status of a prior authorization for Hetlioz that my doctor submitted. My member ID is [number] and the confirmation number is [if available]. Can you tell me if any additional information is needed?"

Requesting expedited review: "I need to request an expedited appeal for Hetlioz denial because the delay in treatment is causing severe sleep disruption that affects my ability to function safely during the day. My doctor can provide documentation of medical urgency."

FAQ

Q: How long does Humana prior authorization take in Florida? A: Standard PA review takes 7-30 days for Part D medications. Expedited review is available within 72 hours if delay could harm your health.

Q: What if Hetlioz is non-formulary on my plan? A: You can request a formulary exception through your prescriber, who must demonstrate medical necessity and that formulary alternatives are not suitable.

Q: Can I get Hetlioz from a regular pharmacy? A: No, Humana requires specialty medications like Hetlioz to be dispensed through CenterWell Specialty Pharmacy for proper handling and support.

Q: Does step therapy apply to Hetlioz? A: Humana's 2026 Part B step therapy list doesn't include oral sleep medications, but individual plans may have requirements to try other sleep aids first.

Q: What happens if my appeal is denied? A: You can escalate to an Independent Review Entity, then to Administrative Law Judge hearings if the dispute amount meets Medicare thresholds ($1,960 for 2026).

Q: How often do I need to renew prior authorization? A: Typically annually, but Humana will notify you before expiration. Your prescriber should submit renewal requests 30-60 days before the current authorization expires.

From our advocates: We've seen cases where patients experienced months of delays because initial PA submissions lacked complete sleep diary data. The most successful approvals include 3-4 weeks of detailed sleep logs showing the characteristic daily delay pattern, combined with a clear prescriber letter explaining why standard sleep medications haven't worked. This comprehensive approach often prevents the back-and-forth that extends approval timelines.

For complex cases involving multiple denials or appeals, Counterforce Health specializes in creating evidence-backed appeals that address the specific denial reasons cited by insurers, helping both patients and clinicians navigate the prior authorization process more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions. For insurance complaints or assistance in Florida, contact the Division of Consumer Services at 1-877-693-5236.

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