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

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Humana in Illinois: Prior Authorization Guide and Appeal Templates

Answer Box: Getting HyperHEP Covered by Humana in Illinois

HyperHEP (hepatitis B immune globulin) requires prior authorization from Humana and is typically non-formulary, but coverage is available with proper documentation. Submit your request within 24-48 hours of exposure through Humana's provider portal or CenterWell Specialty Pharmacy. Include exposure details, patient immunity status, and CDC guideline references. If denied, you have 65 days for internal appeals and 4 months for Illinois external review through the Department of Insurance. Start today: Gather exposure documentation and submit the PA request with medical necessity justification citing CDC post-exposure prophylaxis guidelines.

Table of Contents

  1. Understanding HyperHEP Coverage Requirements
  2. Prior Authorization: The Fastest Path
  3. Medical Necessity Documentation
  4. When Humana Says No: Internal Appeals
  5. Illinois External Review Process
  6. Appeal Templates and Scripts
  7. Cost-Saving Options
  8. FAQ: Common Questions

Understanding HyperHEP Coverage Requirements

HyperHEP (hepatitis B immune globulin) from Grifols provides immediate passive immunity following hepatitis B exposure. Humana typically classifies HyperHEP as non-formulary, requiring prior authorization regardless of whether it's covered under Medicare Part B (medical benefit) or Part D (pharmacy benefit).

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all plans Humana PA Portal
Formulary Status Non-formulary (Tier 5) Plan-specific formulary
Medical vs. Pharmacy Part B if clinic-administered, Part D if dispensed Medicare Coverage Guidelines
Timing Window Within 7 days (percutaneous), 14 days (sexual), 12 hours (perinatal) CDC Guidelines
Appeal Deadline 65 days (internal), 4 months (external) Illinois DOI

The medication typically costs $129-$900+ per vial depending on strength and administration site, making prior authorization crucial for coverage.

Prior Authorization: The Fastest Path

Step-by-Step Approval Process

1. Immediate Documentation (Within 24 Hours)

  • Document exposure incident with date, time, and type
  • Test source patient for HBsAg status when possible
  • Assess patient's hepatitis B immunity status

2. Submit Prior Authorization (24-48 Hours)

  • Use Humana's provider portal or contact CenterWell Specialty Pharmacy
  • Include all required documentation (see checklist below)
  • Request expedited review if within CDC timing window

3. Track and Follow Up

  • Standard decisions: 30 days
  • Expedited decisions: 72 hours
  • Monitor status through provider portal or member services

Required Documentation Checklist

✓ Exposure Details: Type, date, time, circumstances
✓ Source Information: HBsAg status if known
✓ Patient Immunity: Anti-HBs titers, vaccination history
✓ Medical Necessity: CDC guideline references
✓ Dosing Justification: 0.06 mL/kg calculation
✓ Site of Care: In-network provider verification

Tip: Emergency post-exposure cases may bypass initial PA requirements, but submit documentation promptly for reimbursement approval.

Medical Necessity Documentation

CDC Guidelines for Medical Necessity

HyperHEP meets medical necessity criteria when:

  • Patient has documented hepatitis B exposure
  • Patient is susceptible (anti-HBs <10 mIU/mL or unvaccinated)
  • Administration occurs within recommended timeframe
  • No contraindications to immune globulin therapy

Common Exposure Scenarios

Exposure Type Timing Window Required Documentation
Percutaneous (needlestick) Within 7 days (ideally ≤24 hours) Incident report, source HBsAg status
Sexual contact Within 14 days of last exposure Exposure history, patient immunity status
Perinatal Within 12 hours of birth Maternal HBsAg results, birth records

From our advocates: "We've seen the strongest approvals when providers include specific CDC guideline citations in their initial request. One composite case involved a healthcare worker with a needlestick injury—the PA was approved within 48 hours because the provider included the exact CDC recommendation and calculated the dose based on the patient's weight."

When Humana Says No: Internal Appeals

Understanding Denial Reasons

Common denial reasons and solutions:

  • Outside timing window: Document exact exposure date and medical urgency
  • Unclear immunity status: Submit complete vaccination records and titers
  • Non-formulary status: Request formulary exception with medical justification
  • Quantity/dose limits: Provide weight-based dosing calculations

Internal Appeal Process

Level 1 Appeal (65-day deadline)

  1. Submit written appeal via Humana member portal or mail
  2. Include original denial letter and member ID
  3. Attach supporting medical documentation
  4. Request peer-to-peer review if appropriate

Level 2 Appeal (if Level 1 denied)

  • Available for Medicare Advantage members
  • Same documentation requirements
  • Independent medical review
Note: Illinois residents have particularly strong appeal rights under the Health Carrier External Review Act, which provides additional protections beyond federal requirements.

Illinois External Review Process

If Humana denies your internal appeals, Illinois law provides an independent external review option with strict timelines that work in your favor.

Key Illinois Timelines

Filing Deadline: 4 months from final adverse determination (not the shorter 30-day window mentioned in some sources—verify with Illinois Department of Insurance)

Review Timeline:

  • Standard review: 45 days maximum
  • Expedited review: 72 hours for urgent cases

How to File External Review

  1. Complete the External Review Request Form available from the Illinois Department of Insurance website
  2. Submit within 4 months of your final denial letter
  3. Include all medical records supporting your case
  4. No cost to you—Illinois insurers pay for the review

The independent review organization (IRO) will assign a board-certified physician with relevant expertise to review your case. Their decision is binding on Humana.

Illinois Resources for Help

  • Illinois Department of Insurance Consumer Hotline: (877) 527-9431
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
  • Local legal aid organizations for complex cases

Appeal Templates and Scripts

Medical Necessity Appeal Letter Template

[Date]

Humana Medical Review Department
[Address from denial letter]

RE: Appeal for HyperHEP (Hepatitis B Immune Globulin)
Member: [Name], ID: [Member ID]
Date of Service: [Date], Denial Date: [Date]

Dear Medical Director,

I am appealing the [date] denial of HyperHEP for [patient name]. The denial stated: "[exact denial reason]."

**Clinical Justification**:
This [age]-year-old patient requires HyperHEP following [exposure type] on [date]. Patient's hepatitis B status: [immunity status per titers].

**Supporting Evidence**:
• Exposure occurred [timeframe] ago, within CDC recommended window
• CDC guidelines recommend HBIG for this scenario (attached)
• Patient meets medical necessity criteria per attached documentation
• [Address specific denial reason]

This denial contradicts established CDC standards and places the patient at risk for chronic hepatitis B infection. I request immediate approval and am available for peer-to-peer discussion.

Sincerely,
[Provider name, credentials, NPI, contact information]

Attachments: [List all supporting documents]

Peer-to-Peer Call Talking Points

Key points to emphasize:

  • Urgency: "HBIG must be administered time-sensitively to prevent chronic HBV infection"
  • Guidelines: "CDC and ACIP recommend HBIG plus vaccine for non-immune patients after high-risk exposure"
  • Patient-specific factors: "Patient is [immunocompromised/high-risk]; immunity status [negative/unknown]"
  • Standard of care: "FDA-approved, evidence-based therapy; denial risks preventable chronic infection"

Cost-Saving Options

If appeals are unsuccessful or you need immediate access, several programs can help reduce costs:

Manufacturer Support

  • Grifols Patient Assistance: Contact manufacturer directly for eligibility
  • Healthcare provider samples: May be available for emergency use

State and Federal Programs

  • Illinois Medicaid: Expanded coverage may include HBIG
  • 340B pricing: Available at qualified health centers
  • Emergency Medicaid: May cover post-exposure treatment

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create compelling medical necessity arguments that align with payer-specific requirements.

FAQ: Common Questions

How long does Humana prior authorization take in Illinois? Standard PA decisions take up to 30 days, while expedited requests (for urgent medical needs) are decided within 72 hours. Emergency post-exposure cases may receive immediate provisional coverage.

What if HyperHEP is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and showing that formulary alternatives are inappropriate or contraindicated for your situation.

Can I request an expedited appeal in Illinois? Yes, both Humana internal appeals and Illinois external reviews offer expedited options when delays would seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply to hepatitis B immune globulin? Step therapy requirements vary by plan, but emergency post-exposure use typically bypasses step therapy protocols due to the time-sensitive nature of treatment.

What happens if I miss the appeal deadline? Illinois allows some flexibility for good cause delays. Contact the Illinois Department of Insurance immediately to discuss your situation and potential options.

How much does HyperHEP cost without insurance? Retail prices range from approximately $129-$900+ per vial depending on strength and administration site. Most patients require only one dose for post-exposure prophylaxis.

When to Contact Illinois Regulators

If you encounter difficulties with Humana's appeal process or believe your rights have been violated, contact:

  • Illinois Department of Insurance: (877) 527-9431 for consumer assistance
  • File a complaint: Available online through the Illinois DOI website
  • Illinois Attorney General: (877) 305-5145 for health insurance problems

For complex cases requiring specialized support, platforms like Counterforce Health can help develop targeted appeal strategies that address specific payer policies and denial patterns.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and appeal procedures may vary by plan and can change over time.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.