By Counterforce Health Team in Koselugo (selumetinib) —

How to Get Koselugo (selumetinib) Covered by Humana in California: Complete Prior Authorization Guide

Quick Answer: Getting Koselugo Covered by Humana in California

Koselugo (selumetinib) requires prior authorization from Humana for pediatric NF1 patients with symptomatic, inoperable plexiform neurofibromas. Your fastest path: 1) Have your specialist complete Humana's PA form via CoverMyMeds with NF1 diagnosis, imaging showing inoperable tumors, and baseline cardiac/eye exams, 2) If denied, file internal appeal within 65 days, then 3) Request California Independent Medical Review (IMR) through DMHC if still denied. Standard PA decisions take 72 hours; appeals average 30 days. California's IMR has a 68% overturn rate for denials.

Table of Contents

Start Here: Verify Your Plan and Coverage

Before starting any authorization process, confirm your specific Humana plan details:

Check Your Coverage:

  • Log into your Humana member portal or call the number on your insurance card
  • Verify Koselugo's formulary status on your specific plan (Medicare Advantage, Part D, or commercial)
  • Note your plan's formulary tier and any restrictions listed

Key Information to Gather:

  • Your Humana member ID and plan type
  • Current denial letter (if already denied)
  • Complete medical records showing NF1 diagnosis
  • Recent MRI/CT imaging of plexiform neurofibromas
  • Documentation of symptoms and functional impairment
Note: Koselugo is FDA-approved specifically for pediatric patients ≥2 years with NF1 and symptomatic, inoperable plexiform neurofibromas. Adult patients may now be directed to mirdametinib (Gomekli), approved in 2025.

Forms You Need

Primary Prior Authorization Forms

Humana Medicare Prior Authorization Form

  • Available through Humana's provider portal
  • Most recent version verified November 2025
  • Required for Medicare Advantage and Part D members

Humana General Prior Authorization Form

Formulary Exception Forms (if not covered)

If Koselugo isn't on your plan's formulary, you'll need:

  • Coverage Determination/Exception Request Form
  • Available at Humana Medicare forms page
  • Requires prescriber's medical necessity statement

Submission Portals and Methods

Electronic Submission (Fastest)

CoverMyMeds Portal

  • Primary electronic PA channel for Humana
  • Login at CoverMyMeds account portal
  • Select "Humana Prior Authorization Forms" section
  • Real-time determination possible for many requests

Humana Provider Portal

  • Direct submission through Humana's system
  • Access via provider.humana.com
  • Upload supporting documentation directly

Required Documentation Upload

  • NF1 diagnosis confirmation with ICD-10 code
  • MRI/CT imaging showing plexiform neurofibromas
  • Baseline LVEF (cardiac function) assessment
  • Comprehensive ophthalmologic examination results
  • Prior treatment history and outcomes

Fax and Mail Contacts

Fax Numbers

  • Standard PA requests: 877-486-2621
  • Puerto Rico Part D: 855-681-8650
  • Expedited requests: Use same numbers but mark "URGENT" on cover sheet

Mailing Address

Humana Clinical Pharmacy Review
P.O. Box 14601
Lexington, KY 40512-4601

Tip: Always include a detailed cover sheet with member ID, requested drug, and urgency level. Keep fax confirmation receipts.

Specialty Pharmacy Setup

CenterWell Specialty Pharmacy

Humana's preferred specialty pharmacy carries ~96% of specialty drugs on the market, including Koselugo.

Setup Process:

  1. Your prescriber sends prescription to CenterWell
  2. CenterWell initiates PA process through CoverMyMeds
  3. Patient enrollment specialist contacts you for insurance verification
  4. Medication shipped directly to your home with clinical support

Contact: CenterWell Specialty Pharmacy (verify current contact information)

Support Phone Numbers

For Providers

  • Clinical Pharmacy Review: 800-555-CLIN (2546)
  • Hours: Monday-Friday, 8 AM-8 PM local time
  • Professionally Administered Drugs: 866-488-5995

For Members

  • Member Services: Number on your insurance card
  • Pharmacy Help: 800-379-0092
  • Appeals Questions: Same as member services number

Expedited Reviews

Standard timeline: 72 hours
Expedited timeline: 24 hours (requires clinical urgency statement)

California External Review Process

California offers robust external review rights through the Department of Managed Health Care (DMHC).

Independent Medical Review (IMR)

Who Can File: Patient, parent/guardian (for minors), or authorized representative
Cost: Free to file
Success Rate: Approximately 68% of IMR requests result in favorable decisions

Process:

  1. First exhaust internal plan appeals (usually 30 days)
  2. File DMHC IMR Application within 180 days
  3. DMHC assigns to Independent Medical Review Organization
  4. Decision within 30 days (expedited: 7 days or less)

Contact DMHC Help Center: 888-466-2219

Important for Pediatric Cases: Request that the IMR reviewer have pediatric expertise or be affiliated with a children's hospital to ensure appropriate evaluation of rare pediatric conditions.

Step-by-Step: Fastest Path to Approval

Step 1: Gather Documentation (Patient/Family)

Timeline: 1-2 days
What you need:

  • Insurance card and member ID
  • Complete medical records from NF1 specialist
  • Recent imaging reports (MRI/CT)
  • List of all prior treatments and outcomes

Step 2: Prescriber Completes PA (Clinic Staff)

Timeline: 1-2 business days
Action: Submit via CoverMyMeds with complete clinical documentation
Required: NF1 diagnosis, imaging, baseline cardiac/eye exams

Step 3: Humana Review

Timeline: 72 hours standard, 24 hours expedited
What happens: Clinical pharmacists review medical necessity against coverage criteria

Step 4: If Approved

Timeline: 1-3 days
Next steps: Prescription processed through CenterWell Specialty Pharmacy or your preferred specialty pharmacy

Step 5: If Denied - Internal Appeal

Timeline: File within 65 days of denial
Who files: Patient or prescriber can initiate
Decision: Within 30 days for standard, 72 hours for expedited

Step 6: If Still Denied - California IMR

Timeline: File within 180 days of final internal denial
Process: Submit DMHC IMR application
Decision: 30 days standard, 7 days expedited

Common Denial Reasons and Fixes

Denial Reason How to Fix Required Documentation
Missing NF1 diagnosis Submit genetic testing or clinical criteria documentation Genetic test results, clinical photos, family history
Lack of imaging evidence Provide MRI/CT showing inoperable plexiform neurofibromas Radiology reports with measurements, surgical consultation
Missing safety assessments Complete baseline monitoring LVEF/echocardiogram, comprehensive eye exam
Age restrictions Confirm patient ≥2 years old Birth certificate, pediatric records
Not medically necessary Demonstrate functional impairment and symptom severity Pain scales, functional assessments, quality of life measures

Appeals Playbook for California

Level 1: Internal Appeal (Humana)

  • Deadline: 65 days from denial notice
  • How to file: Call member services or submit written appeal
  • Timeline: 30 days for decision (72 hours if expedited)
  • Required: Medical necessity letter from prescriber

Level 2: Independent Medical Review (California)

  • Deadline: 180 days from final internal denial
  • How to file: DMHC online portal or mail/fax
  • Timeline: 30 days standard, 7 days expedited
  • Cost: Free
  • Decision: Binding on health plan

Expedited Appeals Criteria

Request expedited review if delay could:

  • Seriously jeopardize patient's life or health
  • Risk permanent functional impairment
  • Cause severe pain or suffering

Medical Necessity Letter Checklist

Essential Elements for Prescribers

Patient Information:

  • ✓ Confirmed NF1 diagnosis with diagnostic criteria
  • ✓ Age and weight (for dosing calculations)
  • ✓ Specific plexiform neurofibroma locations and characteristics

Clinical Justification:

  • ✓ Documentation of symptoms (pain, functional impairment)
  • ✓ Evidence tumors are inoperable (surgical consultation notes)
  • ✓ Prior treatment failures or contraindications
  • ✓ Baseline safety assessments completed

Regulatory Support:

  • ✓ FDA indication match (pediatric NF1 with symptomatic, inoperable PN)
  • ✓ Appropriate dosing per label (25 mg/m² BID)
  • ✓ Monitoring plan for known side effects

Medical Necessity Statement:

  • ✓ "No covered alternatives would be as effective"
  • ✓ "Delay in treatment may cause irreversible harm"
  • ✓ "Patient meets all FDA-approved indication criteria"

Patient Scripts and Templates

Calling Humana Member Services

"Hi, I'm calling about a prior authorization for my child's medication, Koselugo, for neurofibromatosis. My member ID is [ID number]. Can you tell me the status of our request submitted on [date]? If it's been denied, I'd like to understand the specific reasons and start an internal appeal."

Requesting Expedited Review

"My child has neurofibromatosis with plexiform neurofibromas causing [specific symptoms like pain, airway compression, etc.]. Our doctor says delaying treatment could cause permanent damage. We need this request marked as expedited due to the serious health risk."

Email Template for Medical Records

"Dear [Provider Name],
We need complete medical records for [patient name, DOB] to support a medication appeal with our insurance. Please include: NF1 diagnosis documentation, recent MRI reports, all treatment history, and current symptom assessments. This is needed for a time-sensitive insurance appeal. Thank you."

FAQ

How long does Humana prior authorization take for Koselugo in California?
Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests for urgent medical situations are processed within 24 hours.

What if Koselugo isn't on my Humana formulary?
You can request a formulary exception. Your prescriber must submit a medical necessity letter explaining why covered alternatives aren't appropriate or effective. Formulary exception forms are available online.

Can I request an expedited appeal in California?
Yes, both Humana internal appeals and California IMR can be expedited if delay could seriously jeopardize your health. Your doctor must provide a statement supporting the urgency.

Does step therapy apply to Koselugo?
Step therapy requirements vary by plan. Since Koselugo is the only FDA-approved treatment for pediatric NF1 plexiform neurofibromas, step therapy exceptions are often granted with proper documentation.

What's California's success rate for overturning insurance denials?
California's Independent Medical Review process has approximately a 68% success rate for overturning health plan denials. This applies to all medical necessity disputes reviewed by DMHC.

How much does Koselugo cost without insurance?
Retail prices range from approximately $2,651 for 28×10mg capsules to $6,617 for 28×25mg capsules. Annual costs can reach ~$268,677 depending on dosing. Manufacturer support programs may be available.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to the plan's own rules. Learn more about Counterforce Health.

For complex cases requiring detailed appeal preparation, Counterforce Health provides specialized support for overturning insurance denials through evidence-based appeal strategies tailored to each payer's specific requirements.

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 about treatment decisions and contact qualified legal counsel for specific legal guidance. Insurance coverage policies change frequently—verify current requirements with your specific plan. For additional help with insurance appeals in California, contact the DMHC Help Center at 888-466-2219.

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