By Counterforce Health Team in Jynarque (tolvaptan) —

How to Get Jynarque (Tolvaptan) Covered by Humana in Ohio: Complete Guide with Forms, Appeals, and Contact Numbers

Answer Box: Getting Jynarque Covered by Humana in Ohio

Humana requires prior authorization for Jynarque (tolvaptan) in Ohio. You'll need Mayo Classification 1C-1E documentation showing rapid ADPKD progression, REMS enrollment proof, and ICD-10 code Q61.2. Submit via Humana's provider portal or call 800-457-4708. If denied, you have 65 days to appeal internally, then can request Ohio external review within 180 days through the Ohio Department of Insurance (800-686-1526).

First step today: Verify your nephrologist is REMS-enrolled and gather Mayo classification imaging results showing classes 1C, 1D, or 1E.

Table of Contents

Verify Your Plan and Find Forms

Start by confirming your exact Humana plan type, as requirements vary between Medicare Advantage, commercial plans, and Medicaid managed care. Check your member ID card or log into MyHumana to verify coverage details.

Coverage at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all plans Humana PA Lists Humana Provider Portal
Formulary Status Specialty tier, varies by plan Drug Lists Plan documents
Mayo Classification 1C-1E required Nephrologist imaging Mayo Clinic Calculator
REMS Enrollment Prescriber must be certified Jynarque REMS FDA requirement
Appeal Deadline 65 days from denial Member handbook Medicare guidelines

Required Prior Authorization Forms

Humana processes Jynarque prior authorizations through their pharmacy benefit system. Your nephrologist will need to submit comprehensive documentation proving medical necessity.

Essential Documentation Checklist

Patient Information:

  • Full name, date of birth
  • Humana member ID and policy number
  • Current contact information

Clinical Evidence Required:

  • Diagnosis confirmation: ICD-10 code Q61.2 (ADPKD) with imaging or genetic testing
  • Mayo Classification: Documentation of class 1C, 1D, or 1E showing rapid progression
  • Kidney function: Current eGFR ≥25 mL/min/1.73 m² and ≥5 mL/min/1.73 m²/year decline
  • Liver function: Baseline tests within 30 days, normal results

Prescriber Requirements:

  • Nephrologist enrolled in Jynarque REMS program
  • REMS enrollment verification documentation
  • Signed and dated prior authorization form
Tip: Mayo Classification 1C-1E indicates rapid progression with >3% annual kidney volume growth. Use the validated calculator at Mayo Clinic's website to determine your classification before submitting.

Submission Portals and Methods

Primary Submission Channels

1. Humana Provider Portal

  • Log in at provider.humana.com
  • Navigate to Prior Authorizations section
  • Upload all required documents as PDFs
  • Track status in real-time

2. Phone Submission

  • Call 800-523-0023 for pharmacy prior authorizations
  • Have all documentation ready before calling
  • Request confirmation number for tracking

3. Fax Submission

  • CenterWell Specialty Pharmacy: 877-405-7940
  • Include cover sheet with member ID and drug name
  • Confirm receipt within 24 hours

4. Mail Submission (verify current address)

  • Send certified mail with return receipt
  • Include all documentation in organized packet

Specialty Pharmacy Setup

Once approved, Jynarque will be dispensed through CenterWell Specialty Pharmacy (formerly Humana Specialty Pharmacy). This step is automatic for approved prior authorizations.

CenterWell Specialty Pharmacy Process

Contact Information:

  • Phone: 800-486-2668
  • Fax: 877-405-7940
  • Hours: Monday-Friday 8 AM-11 PM, Saturday 8 AM-6:30 PM

Setup Steps:

  1. CenterWell will contact you within 24-48 hours of PA approval
  2. Verify shipping address and preferred delivery schedule
  3. Complete REMS patient enrollment if not already done
  4. Schedule baseline liver function monitoring
  5. Receive first 2-week supply (standard REMS protocol)
Note: Jynarque requires monthly liver monitoring for the first 18 months. CenterWell will coordinate lab reminders and results tracking with your nephrologist.

Support Phone Numbers

Keep these numbers handy throughout your approval process:

Humana Member Services:

  • General: 800-457-4708 (TTY: 711)
  • Hours: Monday-Friday 8 AM-8 PM local time
  • Use for: PA status, appeals, general coverage questions

CenterWell Specialty Pharmacy:

  • Phone: 800-486-2668
  • Use for: Prescription transfers, delivery scheduling, REMS coordination

Humana Claims Status:

  • Phone: 800-448-6262
  • Use for: Appeal tracking, claim status updates

Always start with the phone number on the back of your Humana ID card for plan-specific support.

Appeals Process in Ohio

If your initial prior authorization is denied, you have multiple appeal levels available in Ohio.

Step-by-Step Appeals Process

1. Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • How to file: Call member services or submit through MyHumana portal
  • Timeline: Humana has 7 days for standard appeals, 72 hours for expedited
  • Required: Copy of denial letter, additional clinical documentation

2. Medicare Reconsideration (Second Level)

  • Deadline: 60 days from first appeal decision
  • Process: Automatic if first appeal upheld
  • Timeline: 60 days for payment decisions, 30 days for service decisions

3. Administrative Law Judge (ALJ)

  • Requirement: Controversy amount ≥$180 (2024 threshold)
  • Timeline: 90 days from reconsideration decision
From our advocates: We've seen Jynarque appeals succeed most often when the nephrologist provides a detailed letter explaining why the patient meets Mayo Classification 1C-1E criteria, includes actual kidney volume measurements, and documents failed conservative management. Complete REMS documentation is essential—incomplete enrollment paperwork is a common cause of preventable denials.

Ohio External Review Process

Ohio residents have additional appeal rights through the state's external review process, which provides an independent medical opinion.

Ohio External Review Details

Eligibility:

  • Must exhaust Humana's internal appeals first
  • Applies to medical necessity denials
  • Available for experimental/investigational treatment denials

Filing Process:

  • Deadline: 180 days from final Humana denial
  • How to request: Contact Humana in writing, by phone, or through MyHumana
  • Cost: Free to members
  • Contact: Ohio Department of Insurance at 800-686-1526

Timeline:

  • Standard review: 30 days from complete request
  • Expedited review: 72 hours (if delay would seriously endanger health)
  • Decision: Binding on Humana if overturned

Ohio DOI Contact Information:

The Ohio external review process is particularly valuable for rare disease medications like Jynarque, as independent medical experts review your case using current medical literature and treatment standards.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient progression documentation Submit Mayo Classification imaging showing 1C-1E MRI/CT with kidney volume measurements, calculator results
REMS enrollment incomplete Verify prescriber certification and patient enrollment REMS enrollment confirmations for both prescriber and patient
Missing baseline labs Provide recent liver function tests LFTs within 30 days, normal results
Non-formulary status Request formulary exception Medical necessity letter explaining why alternatives inadequate
Quantity limits exceeded Document appropriate dosing per FDA label Prescriber attestation of correct titration schedule

Cost Assistance Programs

Even with insurance coverage, Jynarque can have significant out-of-pocket costs. Several assistance programs are available:

Otsuka Patient Assistance:

  • Manufacturer copay assistance program
  • May reduce monthly costs to $10-$35
  • Visit Jynarque.com for current eligibility

Foundation Support:

  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

State Programs:

  • Ohio pharmaceutical assistance programs
  • Contact Ohio Department of Aging: 800-282-1206

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and payer policies to create customized appeal strategies that align with each plan's specific requirements, helping patients navigate complex prior authorization processes more effectively.

FAQ

Q: How long does Humana prior authorization take for Jynarque in Ohio? A: Standard decisions take 7 days; expedited reviews are completed within 72 hours if medical urgency is documented.

Q: What if my nephrologist isn't REMS-enrolled? A: They must complete REMS certification at Jynarque.com before prescribing. This typically takes 1-2 business days.

Q: Can I appeal if Jynarque isn't on my formulary? A: Yes, request a formulary exception by demonstrating medical necessity and inadequacy of covered alternatives.

Q: What Mayo Classification qualifies for Jynarque coverage? A: Classes 1C, 1D, and 1E indicate rapid progression and typically meet coverage criteria. Classes 1A and 1B usually don't qualify.

Q: Does Ohio external review apply to Medicare Advantage plans? A: Yes, Ohio's external review process applies to state-regulated health plans, including many Medicare Advantage plans.

Q: How much does Jynarque cost without insurance? A: Cash prices are approximately $16,000 per month for a typical dose regimen, making insurance coverage essential.

Q: What happens if I miss liver monitoring appointments? A: REMS requires regular monitoring; missed appointments may result in prescription holds until labs are completed.

Q: Can I transfer my prescription to CenterWell Specialty Pharmacy? A: Yes, call 800-486-2668 to initiate a transfer from another specialty pharmacy.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 800-686-1526.

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