By Counterforce Health Team in HyperHEP (hepatitis B immune globulin) —

How to Get HyperHEP Covered by Humana in California: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting HyperHEP Covered by Humana in California

Humana requires prior authorization for HyperHEP (hepatitis B immune globulin) in California. Submit documentation of exposure details, patient immunity status, and timing within 24 hours (up to 7 days) via Humana's provider portal. For denials, file an internal appeal within 65 days, then escalate to Medicare's external review through Livanta (for Medicare Advantage) or California's Independent Medical Review for other plans. Submit PA request here.

First step today: Gather exposure documentation, vaccination history, and anti-HBs levels, then submit via your provider's Humana portal with CPT code 90371.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for HyperHEP in most cases Humana PA Search Tool Humana Provider Portal
Formulary Tier Tier 5 (specialty), 20-40% coinsurance Member portal or formulary PDF Humana Formulary
Timing Window Within 24 hours preferred, up to 7 days CDC Guidelines CDC
Dosing 0.06 mL/kg IM for exposures HyperHEP Prescribing Info FDA Label
CPT Code 90371 (drug), 96372 (IM injection) Medical coding references CMS
Appeals Deadline 65 days from denial notice Humana Appeals Humana Policy

Step-by-Step: Fastest Path to Approval

1. Document the Exposure (Provider)

Timeline: Immediately after exposure

  • Record exposure type (needlestick, sexual contact, perinatal)
  • Note date, time, and source HBsAg status
  • Document patient weight for dosing calculation
  • Submit to: Medical records

2. Check Patient Immunity Status (Provider)

Timeline: Within hours of exposure

  • Order anti-HBs levels (target <10 IU/L indicates need)
  • Review hepatitis B vaccination history
  • Test for current HBsAg, anti-HBc status
  • Submit to: Lab for STAT processing

3. Submit Prior Authorization (Provider)

Timeline: Same day or within 24 hours

  • Use Humana's PA portal or fax to 1-888-447 number
  • Include exposure documentation, serology results, weight-based dosing
  • Request expedited review for urgent cases (72-hour decision)
  • Expected response: Up to 30 days standard, 72 hours expedited

4. Administer if Emergency (Provider)

Timeline: Immediately if life-threatening

  • Administer 0.06 mL/kg IM if urgent exposure
  • Submit retroactive PA with hospital/clinic notes
  • Document medical necessity in chart
  • Follow-up: Submit PA within 48 hours

5. Track Authorization Status (Patient/Provider)

Timeline: 24-48 hours after submission

  • Check Humana provider portal for updates
  • Call Humana provider services if no response
  • Prepare appeal documentation if needed
  • Contact: Number on provider ID card

6. Appeal if Denied (Patient/Provider)

Timeline: Within 65 days of denial

  • File internal appeal via Humana member portal
  • Include additional clinical documentation
  • Request peer-to-peer review if available
  • Expected response: 30 days for pre-service, 60 days for post-service

7. Escalate to External Review (Patient)

Timeline: After internal appeal denial

  • Medicare Advantage: Contact Livanta at 1-877-588-1123
  • Other plans: File with California DMHC at 1-888-466-2219
  • Expected response: 45 days standard, 7 days expedited

Medical Necessity Documentation

Required Clinical Information

Healthcare providers should include these elements in PA submissions:

Exposure Details:

  • Date, time, and nature of exposure (percutaneous, mucosal, sexual)
  • Source person's HBsAg status (positive/unknown high-risk)
  • Incident report number if occupational

Patient Status:

  • Current weight for dosing calculation (0.06 mL/kg)
  • Hepatitis B vaccination history and dates
  • Anti-HBs levels (<10 mIU/mL indicates susceptibility)
  • Current HBsAg, anti-HBc results

Clinical Rationale:

Clinician Tip: Include the specific CDC recommendation that HBIG should be given "as soon as possible, preferably within 24 hours" for maximum effectiveness. This timing urgency often supports expedited review requests.

Supporting Documentation Checklist

  • Exposure incident report or clinical notes
  • Laboratory results (HBsAg, anti-HBs, anti-HBc)
  • Patient vaccination records
  • Weight documentation for dosing
  • Prescriber attestation of medical necessity
  • Hospital/clinic administration records (if already given)

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Timing outside window Provide clinical notes showing urgent exposure Hospital records, incident reports, clinical rationale for delayed presentation
Vaccination history not verified Submit complete immunization records Vaccination cards, provider records, titer results
Quantity/dose limits exceeded Justify weight-based dosing per FDA label Patient weight, FDA dosing guidelines, prescriber calculation
Out-of-network administration site Request network exception for emergency Documentation of emergency circumstances, nearest in-network unavailable
Alternative therapy available Show contraindications to vaccine alone Medical records showing immune compromise, previous vaccine failure

Appeals Process for California

Internal Appeals with Humana

Who Can File: Member, appointed representative, or physician Deadline: 65 calendar days from denial notice Submission Methods:

  • Online: Humana member portal
  • Mail/Fax: Use Appeal/Grievance Form (available in English/Spanish)
  • Phone: Call number on member ID card for oral appeals

Required Documents:

  • Original denial notice
  • Supporting medical records
  • Prescriber's letter of medical necessity
  • Laboratory results and vaccination history
  • Receipts if already purchased

Timeline: 30 days for pre-service appeals, 60 days for post-service appeals

External Review Options

For Medicare Advantage Plans: Contact Livanta (Medicare's Quality Improvement Organization) at 1-877-588-1123 if Humana denies or doesn't respond timely. Livanta provides independent medical review for Medicare beneficiaries.

For Non-Medicare Plans: File an Independent Medical Review (IMR) with the California Department of Managed Health Care:

  • Phone: 1-888-466-2219 (24/7 for urgent cases)
  • Timeline: 45 days standard, 7 days expedited for urgent medical needs
  • Success Rate: Approximately 73% of IMRs result in approval of requested services
  • Cost: Free to consumers
Note: DMHC's IMR primarily applies to California-licensed non-Medicare plans. Medicare Advantage appeals follow federal rules and use Livanta for external review.

Cost-Saving Options

Manufacturer Support

  • Grifols Patient Assistance: Check eligibility for uninsured/underinsured patients
  • Exclusions: Not available for federally funded patients (Medicare, Medicaid)
  • Application: Contact Grifols directly or through specialty pharmacy

Alternative Coverage Sources

  • Occupational Exposure: Employer must provide free post-exposure prophylaxis under OSHA regulations
  • Emergency Medicaid: May cover emergency administration for eligible individuals
  • Hospital Charity Care: Financial assistance programs for uninsured patients

Pharmacy Benefits

HyperHEP is typically covered under medical benefits (injection coverage) rather than pharmacy benefits. Verify with your plan whether it's processed through:

  • Medical claims (CPT 90371, 96372)
  • Specialty pharmacy benefits
  • Buy-and-bill through provider

When to Escalate

Contact California Regulators

Department of Managed Health Care (DMHC):

  • Phone: 1-888-466-2219
  • Website: healthhelp.ca.gov
  • When to call: Plan not following appeal timelines, denial without proper review

California Department of Insurance (CDI):

  • Phone: 1-800-927-4357
  • When to use: For CDI-regulated plans (some PPO/indemnity policies)

Signs You Need External Help

  • Humana denies expedited review for urgent exposure
  • Appeals deadline approaching with no response
  • Multiple denials without clear clinical rationale
  • Plan requesting inappropriate documentation

At Counterforce Health, we help patients and providers navigate complex insurance denials by turning rejection letters into targeted, evidence-backed appeals. Our platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to each plan's own rules, pulling the right clinical evidence and citations to support medical necessity.

Frequently Asked Questions

How long does Humana prior authorization take for HyperHEP in California? Standard PA decisions take up to 30 days. Request expedited review for urgent post-exposure cases—these are decided within 72 hours when medical urgency is documented.

What if HyperHEP is non-formulary on my Humana plan? Submit a formulary exception request with your PA. Include documentation that formulary alternatives (like other HBIG brands) are inappropriate or unavailable for your specific exposure situation.

Can I get emergency administration before PA approval? Yes, for true medical emergencies. Administer immediately and submit retroactive PA within 48 hours with documentation of emergency circumstances and medical necessity.

Does step therapy apply to hepatitis B immune globulin? Generally no, since HBIG is used for specific post-exposure prophylaxis where timing is critical. However, plans may require documentation that active vaccination alone is insufficient.

What's the difference between Medicare Advantage and other Humana appeals in California? Medicare Advantage follows federal appeal rules and uses Livanta for external review. Other Humana plans may be subject to California's DMHC Independent Medical Review process.

How much does HyperHEP cost without insurance in California? Retail prices vary widely, typically ranging from $129-$900+ per vial depending on strength and administration site. Hospital emergency departments generally charge more than outpatient clinics.

Can pharmacists administer HyperHEP in California? Under AB 144 (effective January 2026), pharmacists can initiate ACIP-recommended immunizations for ages 3+ or any age under prescriber protocol. Verify current scope of practice with the California Board of Pharmacy.

What if I miss the 24-hour window for post-exposure prophylaxis? HBIG can still be effective up to 7 days post-exposure, though efficacy decreases over time. For sexual exposure, the window extends to 14 days. Document the timing and clinical rationale in your PA request.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with your insurance plan and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals, Counterforce Health offers specialized support in turning denials into successful approvals through evidence-based advocacy.

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