By Counterforce Health Team in Koselugo (selumetinib) —

How to Get Koselugo (Selumetinib) Covered by Humana in Pennsylvania: Prior Authorization Forms, Appeal Scripts, and Renewal Timeline

Quick Answer: Getting Koselugo Covered by Humana in Pennsylvania

Humana requires prior authorization for Koselugo (selumetinib) in Pennsylvania, typically approved for pediatric patients ≥2 years with NF1 and symptomatic, inoperable plexiform neurofibromas. Submit PA requests 30-60 days early with complete documentation: confirmed NF1 diagnosis, MRI showing plexiform neurofibromas, baseline LVEF/eye exams, and specialist consultation notes. If denied, you have 65 days to appeal internally, then can request Pennsylvania's state external review within 4 months—which overturns ~50% of denials. Start today: Contact your prescribing specialist to gather required documentation and submit through Humana's provider portal.

Table of Contents

  1. Coverage at a Glance
  2. Renewal Triggers: When to Start Early
  3. Evidence Update Requirements
  4. Renewal Documentation Packet
  5. Timeline and Decision Windows
  6. If Coverage Lapses: Bridge Options
  7. Annual Changes to Monitor
  8. Appeals Playbook for Pennsylvania
  9. Cost Support and Patient Assistance
  10. Frequently Asked Questions

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all Humana plans Humana PA Lists
Formulary Tier Specialty Tier (4-5), higher copays Humana Drug Lists
Age Requirements Pediatric patients ≥2 years FDA Label
Diagnosis NF1 with symptomatic, inoperable plexiform neurofibromas FDA Label
Step Therapy Not required (first-in-class) Humana Formulary
Appeals Deadline 65 days from denial notice Humana Appeals
PA Renewal Every 12 months Humana PA Process

Renewal Triggers: When to Start Early

Critical Timing Windows

Start your renewal process 30-60 days before your current authorization expires. Humana's standard PA decisions take up to 15 business days, and any missing documentation can add weeks to the process.

Early renewal triggers include:

  • Authorization expiring within 60 days
  • Upcoming plan year changes (January 1st)
  • Dose adjustments or treatment modifications
  • New insurance enrollment periods
  • Provider changes requiring new PA submissions
Tip: Set calendar reminders for 90, 60, and 30 days before your PA expiration date. This gives you buffer time if complications arise.

Signs You Should Expedite

Request expedited review (72-hour decision) if:

  • Current supply will run out before standard approval
  • Clinical deterioration without continued treatment
  • Hospitalization risk due to treatment interruption

Contact Humana at the member services number on your insurance card to request expedited processing.

Evidence Update Requirements

Response to Therapy Documentation

For renewals, Humana requires evidence that Koselugo continues to provide clinical benefit:

Required imaging updates:

  • MRI with volumetric analysis (within 3-6 months)
  • Comparison to baseline showing stable or improved plexiform neurofibromas
  • Radiologist report documenting response or disease stability

Clinical response documentation:

  • Functional improvement measures (pain scores, mobility, quality of life)
  • Symptom tracking from patient/caregiver reports
  • Physician assessment of continued benefit

Safety Monitoring Results

Cardiac monitoring (required every 3-6 months):

  • LVEF assessment via echocardiogram
  • Documentation that LVEF remains above 50% or within 10% of baseline
  • Cardiology consultation notes if indicated

Ophthalmologic evaluation:

  • Eye exams every 3-6 months during treatment
  • OCT and fundoscopy results
  • Documentation of no retinal toxicity

Laboratory monitoring:

  • CPK levels (monitor for elevation)
  • Liver function tests
  • Complete blood count

Renewal Documentation Packet

Must-Include Documents

  1. Updated Letter of Medical Necessity from treating specialist containing:
    • Confirmed NF1 diagnosis with ICD-10 code (Q85.00 or Q85.01)
    • Current clinical status and symptom assessment
    • Treatment response documentation
    • Safety monitoring results
    • Plan for continued therapy
  2. Recent imaging studies (within 3-6 months):
    • MRI report showing plexiform neurofibromas
    • Volumetric analysis when available
    • Comparison to prior studies
  3. Safety monitoring documentation:
    • Recent LVEF assessment
    • Ophthalmologic evaluation results
    • Laboratory results (CPK, LFTs, CBC)
  4. Clinical notes from recent specialist visits

Brief Letter of Medical Necessity Update Structure

Your specialist should include these key elements:

Paragraph 1: Patient identification, confirmed NF1 diagnosis, current Koselugo dosing Paragraph 2: Treatment response—imaging results, symptom improvement, functional status Paragraph 3: Safety profile—monitoring results, adverse events, dose modifications Paragraph 4: Medical necessity—continued benefit, lack of alternatives, treatment plan

Timeline and Decision Windows

Standard Process Timeline

Step Timeline Action Required
Submit Renewal 30-60 days before expiration Provider submits via portal/fax
Initial Review 5-10 business days Humana reviews completeness
Clinical Decision 15 business days total Medical director review
Notification Within 24 hours of decision Member and provider notified

If Additional Information Needed

Humana may request additional documentation, which can extend the timeline by 10-15 business days. Common requests include:

  • More recent imaging studies
  • Specialist consultation notes
  • Updated safety monitoring results

Counterforce Health specializes in helping patients and clinicians prepare comprehensive renewal packets that address common Humana requirements, reducing the likelihood of delays or additional information requests. Their platform analyzes denial patterns and creates targeted, evidence-backed submissions for specialty medications like Koselugo.

If Coverage Lapses: Bridge Options

Immediate Steps if Authorization Expires

  1. Contact your specialty pharmacy immediately—they may have emergency supplies
  2. Request expedited renewal through Humana (72-hour decision timeline)
  3. Explore temporary coverage options:
    • Alexion OneSource patient assistance program
    • Hospital charity care programs
    • State pharmaceutical assistance programs

Bridge Therapy Coordination

Work with your treatment team to:

  • Document medical necessity for uninterrupted therapy
  • Submit expedited appeal if renewal was denied
  • Coordinate with Alexion OneSource for temporary medication access
  • Consider hospitalization if treatment interruption poses immediate risk
From our advocates: We've seen families successfully bridge coverage gaps by immediately contacting both their specialty pharmacy and the manufacturer's patient assistance program while simultaneously filing expedited appeals. The key is acting within 24 hours of learning about the lapse.

Annual Changes to Monitor

Formulary Changes (January 1st annually)

Monitor for:

  • Tier placement changes (higher copays)
  • New prior authorization requirements
  • Addition of step therapy protocols
  • Quantity limit modifications

Where to check:

Plan Design Shifts

Changes that may affect coverage:

  • New medical management requirements
  • Updated clinical criteria
  • Modified appeals processes
  • Different specialty pharmacy networks

What to Re-verify Annually

  • Specialty pharmacy network participation
  • Copay assistance program eligibility
  • Prior authorization form updates
  • Clinical documentation requirements

Appeals Playbook for Pennsylvania

Internal Appeals Process

Step 1: File with Humana (within 65 days of denial)

  • Submit via Humana member portal or mail
  • Include additional clinical evidence
  • Request peer-to-peer review if appropriate

Step 2: Await Decision (15-30 days)

  • Standard appeals: 30 days
  • Expedited appeals: 72 hours
  • Payment appeals: 60 days

Pennsylvania External Review

If Humana upholds the denial, Pennsylvania offers state-supervised external review:

Eligibility:

  • Commercial insurance plans (not self-funded employer plans)
  • Must have final adverse determination from Humana
  • Submit within 4 months of final denial

Success rate: Pennsylvania's external review program overturns approximately 50% of denials, making it a powerful tool for specialty drug appeals.

How to file:

  1. Complete internal appeals process first
  2. Submit external review request via Pennsylvania Insurance Department portal
  3. Include all medical documentation and denial letters
  4. Independent review organization assigned within 1 business day
  5. Decision within 45 days (72 hours for expedited)

Cost: Free to consumers

Cost Support and Patient Assistance

Alexion OneSource Program

Copay assistance for eligible patients:

  • Reduce out-of-pocket costs to $0 for commercial insurance
  • Not available for Medicare, Medicaid, or TRICARE
  • Enrollment required before first prescription

Contact: 1-888-765-4747 (Monday-Friday, 8:30 AM-8 PM)

Coverage Gap Support

Alexion OneSource provides:

  • Temporary medication access during appeals
  • Prior authorization support
  • Insurance navigation assistance
  • Bridge therapy coordination

Eligibility requirements:

  • US residency
  • Commercial insurance
  • FDA-approved indication
  • Enrolled in OneSource program

Frequently Asked Questions

How long does Humana prior authorization take for Koselugo in Pennsylvania? Standard PA requests are processed within 15 business days. Expedited requests (for urgent medical situations) are decided within 72 hours.

What if Koselugo is non-formulary on my Humana plan? You can request a formulary exception through the same PA process. Include documentation showing medical necessity and lack of suitable formulary alternatives.

Can I request an expedited appeal in Pennsylvania? Yes, both Humana internal appeals and Pennsylvania external reviews offer expedited processing for urgent medical situations where delays could jeopardize health.

Does step therapy apply to Koselugo? No, Koselugo is first-in-class for pediatric NF1 with plexiform neurofibromas, so step therapy requirements typically don't apply.

What happens if my child turns 18 during treatment? Continue current therapy while working with your specialist to transition to appropriate adult treatment options. Mirdametinib (Gomekli) is now FDA-approved for adults with NF1.

How do I know if my Humana plan is subject to Pennsylvania external review? Commercial plans purchased through employers or directly from insurers are eligible. Self-funded employer plans are not covered by state external review.

What documentation strengthens a Koselugo appeal? Include recent MRI with volumetric analysis, documented functional improvements, safety monitoring results, and specialist letters emphasizing continued medical necessity.

Can Counterforce Health help with my Humana appeal? Yes, Counterforce Health specializes in creating evidence-backed appeals for specialty drug denials, including detailed analysis of payer-specific requirements and clinical documentation standards.

Personal Renewal Tracker

90 Days Before Expiration:

  • Review current authorization end date
  • Schedule updated imaging (MRI)
  • Schedule safety monitoring appointments

60 Days Before Expiration:

  • Gather updated clinical documentation
  • Request specialist letter of medical necessity
  • Verify Humana formulary status

30 Days Before Expiration:

  • Submit complete renewal packet
  • Confirm receipt with Humana
  • Set follow-up reminders

If Denied:

  • File internal appeal within 65 days
  • Gather additional evidence
  • Consider Pennsylvania external review if internal appeal fails

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services or the Pennsylvania Health Law Project for free assistance with complex cases.

Sources & Further Reading

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