By Counterforce Health Team in Luxturna (voretigene neparvovec-rzyl) —

How to Get Luxturna Covered by Humana in Michigan: Complete Forms, Appeals Guide & Contact Numbers

Answer Box: Getting Luxturna Covered by Humana in Michigan

Humana requires prior authorization for Luxturna (voretigene neparvovec-rzyl) for biallelic RPE65 mutation-associated retinal dystrophy. Submit requests through Humana's provider portal or fax completed Medicare medication PA forms to 877-486-2621. Required documentation includes CLIA-certified genetic testing confirming biallelic RPE65 mutations, retinal viability assessment, and treatment at Kellogg Eye Center (University of Michigan) - the only qualified facility in Michigan. First step: Verify your Humana plan type and gather genetic test results before submitting the PA request.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Required Forms & Documentation
  3. Submission Portals & Methods
  4. Contact Numbers & Support Lines
  5. Appeals Process in Michigan
  6. Common Denial Reasons & Solutions
  7. Qualified Treatment Centers
  8. Costs & Financial Assistance
  9. FAQ: Luxturna Coverage with Humana

Verify Your Plan & Find the Right Forms

Before starting your Luxturna prior authorization, confirm your specific Humana plan type, as this determines which forms and processes apply.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana Medicare Advantage plans Humana Medication PA List Official PA list
Formulary Status Non-formulary/specialty tier Check plan formulary Plan documents
Qualified Center Must treat at Spark-designated facility Only Kellogg Eye Center in Michigan Treatment center locator
Genetic Testing Biallelic RPE65 mutations confirmed CLIA-certified lab report required FDA label requirement
Age Requirements Typically 3-64 years Varies by plan policy Payer-specific criteria

Plan Types & Forms:

  • Medicare Advantage/Dual Plans: Use Medicare Medication Preauthorization forms
  • Commercial Plans: Use standard Humana PA forms
  • Medicaid Plans: Follow state Medicaid PA process
Tip: Call the number on your Humana ID card to confirm your exact plan type and current PA requirements before gathering documentation.

Required Forms & Documentation

Step-by-Step: Fastest Path to Approval

1. Gather Essential Documentation (Patient/Clinic)

  • Insurance card and member ID
  • CLIA-certified genetic test report showing biallelic RPE65 mutations
  • Retinal imaging (OCT showing viable posterior retina >100 μm thickness)
  • Visual function tests (visual fields, FST, MLMT)
  • Prior treatment history and failures
  • Timeline: 1-2 weeks to collect

2. Complete Medical Necessity Letter (Prescribing Physician)

  • Confirmed biallelic RPE65 mutation-associated retinal dystrophy diagnosis
  • Progressive vision loss documentation
  • Evidence of viable retinal cells
  • Statement that treatment will occur at Kellogg Eye Center
  • Timeline: 2-3 business days

3. Submit PA Request (Provider)

  • Use Humana provider portal or fax forms
  • Attach all supporting documentation
  • Request expedited review if urgent
  • Timeline: Same day submission possible

4. Follow Up (Provider/Patient)

  • Track status via provider portal
  • Respond promptly to requests for additional information
  • Expected decision: 72 hours standard, 24 hours expedited

5. If Approved: Coordinate Treatment

  • Schedule at Kellogg Eye Center
  • Verify coverage details with Humana billing
  • Timeline: 2-4 weeks for scheduling

6. If Denied: File Internal Appeal

  • Submit within 60 days of denial notice
  • Include additional clinical evidence
  • Timeline: 30 days for decision

7. External Review (if needed)

  • File with Michigan DIFS within 127 days
  • Include physician letter supporting medical necessity
  • Timeline: 60 days maximum, often faster

Clinician Corner: Medical Necessity Letter Checklist

Your medical necessity letter should address these key elements:

✓ Diagnosis: Confirmed biallelic RPE65 mutation-associated retinal dystrophy with ICD-10 codes ✓ Genetic Evidence: Reference specific CLIA-certified test results showing biallelic pathogenic variants ✓ Clinical Status: Progressive vision loss, current visual function, impact on daily activities ✓ Retinal Viability: OCT findings showing viable retinal tissue suitable for gene therapy ✓ Treatment Rationale: FDA-approved indication, lack of alternative therapies ✓ Qualified Center: Confirmation of treatment at Kellogg Eye Center ✓ Guidelines: Reference FDA labeling and relevant ophthalmology society recommendations

Note: Include specific measurements from OCT and visual function tests rather than general statements about "viable retina."

Submission Portals & Methods

Online Submission (Preferred)

Humana Provider Portal

  • URL: provider.humana.com
  • Access: Requires provider account setup
  • Features: Real-time status tracking, document upload, expedited review requests
  • Advantage: Fastest processing and immediate confirmation

Availity Platform

  • Many Humana PAs route through Availity
  • Electronic submission with attachment capabilities
  • Integration with many EHR systems

Fax Submission

Medicare Medication PA Fax: 877-486-2621 Clinical Intake Team: 800-523-0023 (for urgent cases)

Fax Cover Sheet Tips:

  • Include patient name, Humana member ID, and provider NPI
  • Mark "URGENT" if requesting expedited review
  • Number pages clearly (e.g., "Page 1 of 8")
  • Include callback number for questions

Mail Submission (Backup)

Use fax or online submission when possible. If mailing is necessary, confirm the current address through Humana provider services, as addresses change periodically.

Contact Numbers & Support Lines

Provider Support

  • Clinical Intake Team: 800-523-0023 (24/7, for PA questions and clinical escalation)
  • Medicare Advantage PA: 866-488-5995 (providers)
  • General Provider Relations: 800-626-2741 (Mon-Fri, 8 AM-5 PM CT)

Member Support

  • General Member Services: Number on back of ID card
  • Medicare Advantage Members: 866-773-5959
  • Case Management: 866-868-5092 (Mon-Fri, 9:30 AM-5:15 PM EST)

Specialty Pharmacy

  • CenterWell Specialty Pharmacy: 800-486-2668 (TTY 711)
  • Handles specialty medication coordination after PA approval

What to Ask When Calling:

  • Current PA status and any pending information requests
  • Expected timeline for decision
  • Appeal rights if denied
  • Case management referral for complex cases

Appeals Process in Michigan

Internal Appeals with Humana

Timeline: 60 days from denial notice to file appeal Method: Submit through provider portal, fax, or mail Decision Time: 30 days standard, 72 hours expedited

Required for Appeal:

  • Copy of original denial letter
  • Additional clinical evidence addressing denial reasons
  • Updated medical necessity letter
  • Peer-reviewed literature supporting Luxturna use

Michigan External Review

For commercial Humana plans (not Medicare Advantage), Michigan residents can request external review through the Department of Insurance and Financial Services (DIFS).

Key Details:

  • Timeline: 127 days from final internal denial
  • Cost: Free to patients
  • Method: Online DIFS form or paper submission
  • Decision Time: 60 days maximum, 72 hours for expedited
  • Contact: 877-999-6442
Important: Medicare Advantage appeals generally follow federal Medicare appeal processes, not Michigan DIFS external review.

When to Request Expedited Review

Request expedited appeals when:

  • Rapid vision deterioration is documented
  • Patient is approaching age limits for treatment
  • Retinal viability is declining based on recent imaging

Include a physician letter stating why delay would seriously jeopardize the patient's vision or ability to benefit from treatment.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient genetic testing Submit CLIA-certified report Biallelic RPE65 mutation confirmation
Not at qualified center Confirm Kellogg Eye Center treatment Letter from center confirming patient acceptance
Inadequate retinal viability Provide detailed imaging OCT with measurements, visual function tests
Missing prior authorization Resubmit complete PA packet All required forms and documentation
Experimental/investigational Cite FDA approval FDA label, peer-reviewed efficacy studies

Scripts for Common Situations

Patient calling about PA status: "I'm calling to check the status of my prior authorization for Luxturna, member ID [number]. Can you tell me if any additional information is needed and the expected timeline for a decision?"

Provider requesting peer-to-peer review: "I'm requesting a peer-to-peer review for my patient's Luxturna prior authorization. The patient has confirmed biallelic RPE65 mutations and progressive vision loss. When can we schedule this review?"

Qualified Treatment Centers

Kellogg Eye Center - University of Michigan

  • Address: 1000 Wall Street, Ann Arbor, MI 48105
  • Designation: Only Spark Therapeutics-certified center in Michigan
  • Specialties: Inherited retinal diseases, genetic testing interpretation, Luxturna administration

Why This Matters for Coverage: Humana and other insurers require treatment at designated centers. Attempting treatment elsewhere will result in denial, even with proper PA approval.

Services Provided:

  • Genetic counseling and testing coordination
  • Retinal viability assessment
  • Pre-surgical evaluation
  • Luxturna administration (bilateral, separate procedures)
  • Post-operative monitoring

Costs & Financial Assistance

List Price & Coverage

  • Luxturna List Price: $425,000 per eye ($850,000 for bilateral treatment)
  • Typical Patient Cost: Varies by plan; often $0-$500 with PA approval

Financial Assistance Programs

My Spark Generation (Manufacturer Program)

  • Contact: 844-SPARK4U (844-772-7548)
  • Services: Insurance navigation, copay assistance, financial counseling
  • Eligibility: Most commercially insured patients

Foundation Support

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Check eligibility through Counterforce Health for current grant availability
From our advocates: We've seen families reduce their out-of-pocket costs from thousands to under $100 by combining manufacturer copay programs with foundation grants. The key is applying early - some programs have limited annual funding that gets depleted.

FAQ: Luxturna Coverage with Humana

Q: How long does Humana prior authorization take in Michigan? A: Standard decisions within 72 hours, expedited within 24 hours for urgent cases. Complete documentation reduces delays.

Q: What if Luxturna is non-formulary on my plan? A: Non-formulary status doesn't prevent coverage. Submit a formulary exception request with strong medical necessity documentation.

Q: Can I request expedited review? A: Yes, if your physician documents that delay would seriously jeopardize your vision or ability to benefit from treatment.

Q: Does step therapy apply? A: Typically no, since Luxturna is the only FDA-approved gene therapy for biallelic RPE65 deficiency. Document lack of alternatives.

Q: What happens if I'm denied? A: File internal appeal within 60 days, then external review through appropriate channels (DIFS for commercial, Medicare process for MA plans).

Q: Can I get treatment outside Michigan? A: Yes, but it must be at a Spark-designated center. Travel costs may not be covered, but treatment will be if PA is approved.

Q: How do I know if my genetic testing is adequate? A: Must be CLIA-certified lab showing biallelic pathogenic or likely pathogenic RPE65 variants. Single variants or variants of uncertain significance typically don't qualify.

Q: What if my vision is too poor for treatment? A: Luxturna requires some viable retinal cells. Your retinal specialist at Kellogg Eye Center will assess eligibility through imaging and function tests.

Getting Help with Your Appeal

If you're struggling with Humana's prior authorization process or facing a denial, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals that align with your plan's specific requirements.

For Luxturna cases, we help gather the right evidence - FDA labeling, peer-reviewed studies, and specialty guidelines - and weave them into appeals with the required clinical facts. We understand payer-specific workflows and produce letters that meet procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Humana and consult with qualified healthcare providers about treatment decisions. For official Michigan insurance appeal information, contact the Department of Insurance and Financial Services at 877-999-6442.

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