By Counterforce Health Team in Krystexxa (pegloticase) —

How to Get Krystexxa (Pegloticase) Covered by Humana in Michigan: Complete PA Forms and Appeals Guide

Answer Box: Getting Krystexxa Covered by Humana in Michigan

Krystexxa (pegloticase) requires prior authorization from Humana Medicare Advantage plans in Michigan. Your fastest path to approval: (1) Verify your rheumatologist has documented failure of allopurinol and febuxostat at maximum doses for ≥3 months each, (2) Submit PA request via Humana provider portal with G6PD test results and current methotrexate plan, (3) If denied, file internal appeal within 65 days, then Michigan DIFS external review within 127 days. Call 877-999-6442 for Michigan appeals assistance.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Process
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Coordination
  6. Support Phone Lines and Case Management
  7. Michigan Appeals and External Review
  8. When to Update Your Resources

Verify Your Plan and Find the Right Forms

Before starting your Krystexxa (pegloticase) approval process, confirm you have a Humana Medicare Advantage plan that covers professionally administered drugs. Krystexxa requires prior authorization for all 2024-2025 Humana plans and is coded as J2507 (per 1 mg, with 8 units billed per 8mg vial).

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for J2507/Krystexxa Patient ID, gout diagnosis, treatment history Humana 2025 PA List
Prescriber Rheumatologist required Rheumatology consultation notes Humana policy standards
Step Therapy Failed allopurinol + febuxostat (≥3 months each) Dates, doses, lab results showing SUA >6 mg/dL PA requirements
G6PD Testing Normal results required (contraindicated if deficient) Recent lab report FDA label requirement
Methotrexate Concurrent use or documented contraindication Current medication list or clinical rationale 2022 label update

Prior Authorization Forms and Requirements

Step-by-Step: Fastest Path to Approval

  1. Download the PA Form (Provider): Access Humana's professionally administered drug PA form via the provider portal or search "Prior Authorization for Professionally Administered Drugs" on the Humana provider site.
  2. Gather Required Documentation:
    • Insurance card and member ID
    • Gout diagnosis with ICD-10 codes
    • Documentation of allopurinol failure (dates, doses, duration ≥3 months)
    • Documentation of febuxostat failure (dates, doses, duration ≥3 months)
    • Serial uric acid levels showing persistent elevation >6 mg/dL
    • G6PD test results (normal)
    • Current methotrexate therapy or contraindication rationale
  3. Complete Medical Necessity Section: Your rheumatologist should detail why Krystexxa is medically necessary, referencing the 2020 ACR gout guidelines and FDA labeling for refractory chronic gout.
  4. Submit Within Timeline: Standard PA decisions take 15-30 days; expedited reviews (with physician attestation of urgency) are completed within 72 hours.
Tip: New Humana enrollees get a 90-day grace period for medications they were taking before enrollment, but this doesn't waive PA requirements for new starts.

Submission Portals and Upload Process

Provider Portal Submission

Primary Method: Log into Humana's provider portal or the Availity portal for real-time submission and tracking. Upload all supporting documents (lab results, consultation notes, prior therapy records) directly through the portal system.

Required Account Setup: If not already registered, contact [email protected] with "Join the network" in the subject line, including pharmacy name, NPI, contact information.

Member Portal Option

Patients can file appeals directly at www.humana.com/denial using the Request for Redetermination form. However, provider submission is typically more efficient for complex specialty medications.

Fax Numbers and Mailing Addresses

Fax Submission

  • General Part D PA requests: 877-486-2621
  • Professionally administered drugs (recommended for Krystexxa): 1-888-447-3430 to the Medication Intake Team (MIT)
  • Appeals: 1-877-556-7005

Mailing Address

Humana Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4546

Note: Always include a cover sheet with member ID, prescriber name, drug name (Krystexxa/pegloticase), and HCPCS code J2507.

Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy

Humana's specialty pharmacy, CenterWell, handles Krystexxa distribution and infusion coordination. Contact: 844-486-2668 (TTY: 711), Monday-Friday 8am-8pm ET, Saturday 8am-6pm ET.

For Michigan Providers:

  1. Verify network participation or join via [email protected]
  2. Use CAQH ProView for credentialing (call 800-233-1468 for assistance)
  3. Coordinate infusion scheduling through CenterWell after PA approval
  4. Fax orders to 877-405-7940 or call the main CenterWell line

Dual-Eligible Special Needs Plans (D-SNP)

For Humana Dual Integrated plans in Michigan, contact Provider Services at 855-281-6070 (TTY: 711) for specialized assistance with dual Medicare-Medicaid coordination.

Support Phone Lines and Case Management

Key Contact Numbers

  • Humana Clinical Pharmacy Review (HCPR): 800-555-2546 (Mon-Fri 8am-8pm local time) for high-cost specialty medication questions
  • Member Services: 866-274-9834 for pharmacy benefits questions
  • Provider Services: Use the Humana provider portal contact page for current regional numbers
  • Expedited Appeals: 1-800-451-4651 (requires physician attestation of medical urgency)

What to Ask When You Call

For PA Status Checks:

  • "I need to check the status of prior authorization request for member [ID], Krystexxa J2507"
  • "What additional documentation is needed?"
  • "Can this be expedited based on medical necessity?"

For Denials:

  • "I'd like to file an internal appeal for the Krystexxa denial"
  • "What's the fastest way to submit supporting clinical documentation?"
  • "Can we schedule a peer-to-peer review with the medical director?"

Michigan Appeals and External Review

Internal Appeals with Humana

Timeline: You have 65 days from the denial notice to file an internal appeal with Humana. Standard decisions within 7 days; expedited within 72 hours with physician support.

Submission Methods:

Michigan DIFS External Review

If Humana denies your internal appeal, you can file an external review with the Michigan Department of Insurance and Financial Services (DIFS).

Timeline: 127 days from Humana's final denial to file with DIFS (Michigan's specific timeframe, longer than the federal 120-day standard).

How to File:

  1. Complete DIFS external review form online at michigan.gov/difs or request paper forms
  2. Include Humana's denial letter, medical necessity documentation, and your rationale
  3. DIFS assigns to an Independent Review Organization (IRO) with medical experts
  4. Standard decision within 60 days; expedited within 72 hours with physician letter

Contact DIFS: 877-999-6442 for forms and assistance

Important: If the IRO overturns Humana's denial, the insurer must provide coverage within 7 days.

Clinician Corner: Medical Necessity Letter Checklist

When writing your medical necessity letter for Krystexxa, include:

  • Problem Statement: Chronic refractory gout with tophi/joint damage despite optimal conventional therapy
  • Prior Treatments: Document specific dates, doses, and duration of allopurinol (≥3 months at maximum tolerated dose) and febuxostat (≥3 months at maximum tolerated dose)
  • Clinical Rationale: Reference 2020 ACR gout guidelines, FDA labeling for refractory cases, and patient-specific factors
  • Laboratory Support: Serial uric acid levels demonstrating persistent elevation >6 mg/dL despite conventional therapy
  • Safety Considerations: G6PD normal results, plan for methotrexate co-therapy per 2022 label update
  • Monitoring Plan: Uric acid levels before each infusion, infusion reaction protocols

When to Update Your Resources

Regular Check Schedule

  • Quarterly: Review Humana's PA lists for policy changes
  • Annually: Confirm portal access, fax numbers, and contact information
  • Policy Updates: Monitor FDA label changes and ACR guideline updates that may affect coverage criteria

Key Update Sources:

  • Humana provider portal notifications
  • Michigan DIFS website for appeals process changes
  • CenterWell Specialty Pharmacy communications

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient step therapy Provide detailed records of allopurinol and febuxostat trials Pharmacy records, lab results, clinical notes
Missing G6PD test Submit recent lab results showing normal G6PD Laboratory report within past year
Non-rheumatologist prescriber Transfer care or obtain rheumatology consultation Rheumatology consultation note
Inadequate uric acid documentation Provide serial labs showing persistent elevation Multiple lab results over time
Missing methotrexate plan Document current MTX therapy or contraindications Current medication list or clinical rationale

Costs & Patient Assistance

While navigating insurance approval, consider these cost-mitigation options:

  • Amgen SupportPlus: Patient assistance program for eligible uninsured/underinsured patients
  • Hospital charity care: Many infusion centers offer financial assistance programs
  • State pharmaceutical assistance: Michigan may have additional programs for qualifying residents

FAQ

Q: How long does Humana PA take for Krystexxa in Michigan?
A: Standard PA decisions within 15-30 days; expedited reviews within 72 hours with physician attestation of medical urgency.

Q: What if Krystexxa is non-formulary on my Humana plan?
A: File a formulary exception request using the same PA process, emphasizing medical necessity and lack of formulary alternatives.

Q: Can I request an expedited appeal?
A: Yes, call 1-800-451-4651 with physician documentation that delay would jeopardize your health.

Q: Does Michigan have special protections for specialty drug appeals?
A: Yes, Michigan's 127-day external review timeline is longer than federal requirements, and DIFS offers expedited 72-hour reviews for urgent cases.

Q: What happens if I'm transitioning from another insurer?
A: Humana provides up to 31-day temporary supply for new members, but PA requirements still apply for ongoing coverage.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed responses. Our platform helps patients and providers navigate complex prior authorization requirements and appeals processes more effectively. Visit counterforcehealth.org to learn how we can help streamline your coverage challenges.

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 plan for specific coverage decisions. Coverage policies and procedures may change; verify current requirements with Humana and Michigan DIFS before proceeding.

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