By Counterforce Health Team in Koselugo (selumetinib) —

How to Get Koselugo (Selumetinib) Covered by Humana in Ohio: Complete Appeals Guide

Answer Box: Getting Koselugo Covered by Humana in Ohio

Koselugo (selumetinib) requires prior authorization from Humana for pediatric NF1 patients with symptomatic, inoperable plexiform neurofibromas. Your fastest path to approval: (1) Have your specialist complete Humana's PA form with NF1 diagnosis confirmation, imaging showing inoperable PN, and baseline cardiac/eye exams, (2) Submit via Humana's provider portal within 72 hours for standard review, (3) If denied, file an internal appeal within 65 days, then request external review through Ohio Department of Insurance within 180 days. Start by calling Humana member services at the number on your insurance card to request PA forms.

Table of Contents

Eligibility Quick Check

Does your child qualify for Koselugo coverage? Use this decision tree:

Likely Eligible ✅

  • Child is 2+ years old with confirmed NF1 diagnosis
  • Has symptomatic, inoperable plexiform neurofibromas documented by MRI
  • Prescribed by pediatric oncologist or neurologist
  • Baseline LVEF and eye exam completed

Next step: Gather documentation and submit PA request

Possibly Eligible ⚠️

  • NF1 diagnosis suspected but not fully documented
  • Plexiform neurofibromas present but operability unclear
  • Missing baseline safety evaluations

Next step: Complete diagnostic workup and safety assessments

Not Yet Eligible ❌

  • Child under 2 years old
  • No confirmed plexiform neurofibromas
  • Alternative treatments haven't been considered

Next step: Discuss alternatives with your specialist or prepare for formulary exception

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required for all Koselugo requests Humana provider portal Humana PA Resources
Specialty Tier High cost-sharing tier placement Member formulary Humana Formulary
Age Requirement FDA-approved for pediatric patients ≥2 years Drug label FDA Prescribing Information
Diagnosis Documentation Confirmed NF1 with symptomatic, inoperable PN Clinical notes, imaging AstraZeneca PA Criteria
Baseline Monitoring LVEF assessment and eye exam required Cardiology/ophthalmology reports Koselugo HCP Site
Appeal Deadline 65 days for Medicare Advantage Denial notice CMS Appeals Process

Step-by-Step: Fastest Path to Approval

1. Confirm Your Humana Plan Type

Who does it: You or your caregiver
What you need: Insurance card
Action: Check if you have Medicare Advantage or commercial coverage, as appeal processes differ
Timeline: 5 minutes
Source: Humana Member Services

2. Schedule Required Baseline Tests

Who does it: Your care team
What you need: Echocardiogram for LVEF, comprehensive eye exam
Action: Schedule before PA submission—these are safety requirements
Timeline: 1-2 weeks
Source: Koselugo Safety Monitoring

3. Gather Diagnostic Documentation

Who does it: Your specialist's office
What you need: NF1 diagnosis confirmation, MRI showing PN, symptom documentation
Action: Request complete medical records package
Timeline: 3-5 business days
Source: Common PA Criteria

4. Submit Prior Authorization Request

Who does it: Prescribing physician
What you need: Completed PA form with all supporting documents
Action: Submit via Humana provider portal or fax
Timeline: 72 hours for standard review
Source: Humana PA Process

5. Track Your Request

Who does it: You or clinic staff
What you need: PA reference number
Action: Follow up if no response within timeline
Timeline: Check status after 3 business days
Source: Member Portal

Clinician Corner: Medical Necessity Documentation

For Healthcare Providers: Strengthen your Koselugo PA requests with this documentation checklist

Essential Clinical Elements

NF1 Diagnosis Confirmation:

  • Document at least 2 NIH diagnostic criteria
  • Include genetic testing results if available
  • Note family history when relevant

Plexiform Neurofibroma Documentation:

  • MRI reports showing PN location and characteristics
  • Clinical assessment of symptoms (pain, functional impairment, disfigurement)
  • Surgical consultation notes confirming inoperability

Safety Prerequisites:

  • Baseline LVEF by echocardiogram (must be above institutional lower limit)
  • Comprehensive ophthalmologic evaluation
  • Plan for ongoing monitoring per FDA requirements

Medical Necessity Statement Template: "This [age]-year-old patient with genetically confirmed NF1 has symptomatic, inoperable plexiform neurofibromas causing [specific symptoms]. Baseline cardiac and ophthalmologic evaluations are complete and normal. Koselugo is the only FDA-approved treatment for this indication in pediatric patients."

Key References for Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Diagnosis not confirmed" Submit genetic testing or detailed clinical criteria NIH Diagnostic Guidelines
"Not medically necessary" Provide symptom documentation and functional impact Clinical notes, quality of life assessments
"Missing safety evaluations" Complete baseline LVEF and eye exams Cardiology and ophthalmology reports
"Non-formulary drug" Request formulary exception with supporting statement Formulary Exception Process
"Step therapy required" Document contraindications to alternatives Medical literature showing Koselugo is first-line

Appeals Playbook for Humana in Ohio

Level 1: Internal Appeal (Redetermination)

Deadline: 65 days from denial notice
Timeline: 7 days for Part D, 30 days for Medicare Advantage
How to file: Online, phone, or written request
Required: Denial notice, additional medical evidence
Contact: Humana Appeals

Level 2: Independent Review

Deadline: 60 days from Level 1 denial
Timeline: 30 days for standard review
Process: Automatic forwarding to Independent Review Entity
Your role: Submit any additional supporting evidence

Level 3: Ohio External Review

Deadline: 180 days from final internal denial
Timeline: 30 days standard, 72 hours expedited
How to file: Through your health plan, which notifies Ohio DOI
Contact: Ohio Department of Insurance at 800-686-1526

From our advocates: "We've seen Koselugo appeals succeed when families include photos showing functional impact alongside MRI reports. One family documented how their child's facial PN affected eating and speaking—that visual evidence helped the external reviewer understand medical necessity beyond just the imaging."

Costs & Patient Support Options

Manufacturer Support:

  • AstraZeneca Access Navigator program
  • Copay assistance for eligible patients
  • Patient assistance program for uninsured/underinsured

Foundation Resources:

  • National Organization for Rare Disorders (NORD)
  • Children's Tumor Foundation
  • HealthWell Foundation

Estimated Costs: Annual treatment cost approximately $268,677 based on pediatric dosing. Humana specialty tier cost-sharing typically 25-33% coinsurance.

When to Escalate to Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Humana delays exceed regulatory timelines
  • You're denied access to external review
  • Procedural violations occur during appeals

Ohio DOI Consumer Hotline: 800-686-1526
Online Complaint Form: Available on ODI website

FAQ: Humana Coverage for Koselugo in Ohio

How long does Humana prior authorization take?
Standard PA requests: 72 hours. Expedited requests (if delay would jeopardize health): 24 hours.

What if Koselugo isn't on Humana's formulary?
Request a formulary exception through your prescriber. Include medical necessity documentation and why covered alternatives aren't appropriate.

Can I get an expedited appeal in Ohio?
Yes, for urgent medical situations. Request expedited review if waiting would seriously jeopardize your child's health—decision within 72 hours.

Does step therapy apply to Koselugo?
Generally no, since Koselugo is first-line treatment for pediatric NF1 with plexiform neurofibromas. If step therapy is required, document why alternatives are contraindicated.

What happens if my appeal is denied at all levels?
You retain the right to legal action or file complaints with Ohio regulators. Consider consulting with a healthcare attorney specializing in insurance appeals.

How often do Koselugo appeals succeed?
While specific statistics aren't published, appeals with complete diagnostic documentation and clear medical necessity tend to be successful, especially at external review level.

About Counterforce Health: Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by creating evidence-backed, payer-specific rebuttal letters. Our platform analyzes denial reasons and drafts targeted appeals using the right clinical evidence and procedural requirements for your specific insurance plan.

When navigating complex specialty drug approvals like Koselugo, having expert support can make the difference between approval and prolonged delays. Counterforce Health streamlines this process by identifying exactly what documentation your insurer requires and helping you build the strongest possible case for coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with insurance appeals in Ohio, contact the Ohio Department of Insurance at 800-686-1526.

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