By Counterforce Health Team in Mycapssa (octreotide, oral) —

How to Get Mycapssa (Octreotide Oral) Covered by Humana in Washington: Complete Prior Authorization Guide

Answer Box: Getting Mycapssa Covered by Humana in Washington

Mycapssa (oral octreotide) requires prior authorization from Humana and typically needs documentation of prior response to injectable octreotide or lanreotide for acromegaly. Here's the fastest path:

  1. Gather documentation: Confirmed acromegaly diagnosis (elevated IGF-1), prior injectable SSA therapy records, and endocrinologist prescription
  2. Submit PA request: Use Humana's provider portal with medical necessity letter
  3. If denied: File internal appeal within 60 days, then external review through Washington's IRO process if needed

Timeline: Standard PA decisions within 72 hours; appeals within 7 days standard or 72 hours expedited.

Table of Contents

Who Should Use This Guide

This guide helps Washington residents with Humana Medicare Advantage or Part D plans who need Mycapssa (oral octreotide) for acromegaly. Mycapssa is the first oral formulation of octreotide, offering an alternative to injections for patients who've responded to injectable somatostatin analogs.

Expected outcome: With proper documentation, most medically appropriate requests get approved. Humana's Medicare Advantage PA denial rate is relatively low at ~3.5%, but specialty medications like Mycapssa often face step therapy requirements.

Member & Plan Basics

Coverage Verification

Before starting, confirm your Humana plan details:

  • Active enrollment in Humana Medicare Advantage or Part D
  • Specialty pharmacy benefits (Mycapssa requires specialty pharmacy dispensing)
  • Current formulary status - check Humana's formulary tool

Key Plan Requirements

Requirement Details Source
Prior Authorization Required for all Mycapssa prescriptions Humana PA Lists
Specialty Pharmacy Must use Humana-contracted specialty pharmacy Humana Pharmacy
Prescriber Requirements Often requires endocrinologist Plan-specific

Clinical Criteria Requirements

Primary Indication

Mycapssa is FDA-approved for long-term maintenance treatment of acromegaly in adults who have responded to octreotide or lanreotide. Off-label use faces higher denial risk.

Step Therapy Documentation

Humana typically requires evidence of:

  1. Prior injectable SSA therapy (octreotide LAR or lanreotide)
  2. Documented response to injectable therapy
  3. Clinical rationale for switching to oral formulation

Required Lab Values

  • Elevated IGF-1 (above age-adjusted normal range)
  • Growth hormone levels if available
  • Baseline biochemical confirmation of acromegaly diagnosis
Clinician Note: Document specific IGF-1 values and reference ranges. Generic statements like "elevated IGF-1" may trigger denials.

Documentation Packet Essentials

Medical Necessity Letter Components

Your endocrinologist should include:

  1. Confirmed acromegaly diagnosis with ICD-10 code E22.0
  2. Prior treatment history:
    • Specific injectable SSA used (octreotide LAR/Sandostatin LAR or lanreotide/Somatuline Depot)
    • Dosage, frequency, and duration
    • Clinical response documented with IGF-1 levels
  3. Rationale for Mycapssa:
    • Patient preference to avoid injections
    • Injection site reactions or access issues
    • Maintained disease control expectation
  4. Supporting lab values and dates
  5. Treatment goals and monitoring plan

Required Attachments

  • Recent IGF-1 and growth hormone levels
  • Prior therapy documentation
  • Relevant clinic notes
  • Prescription with NDC 72606-731-30 (verify current NDC)

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing the specific denial basis and drafting point-by-point rebuttals aligned to each plan's requirements—exactly what's needed when Humana denies specialty medications like Mycapssa.

Submission Process

Step-by-Step Submission

  1. Complete PA form: Use Humana's current prior authorization form
  2. Submit via portal: Humana Provider Portal for fastest processing
  3. Include all documentation: Medical necessity letter and attachments
  4. Track submission: Note confirmation number and submission date
  5. Follow up: Check status after 48-72 hours

Timeline Expectations

  • Standard review: 72 hours after complete submission
  • Expedited review: 24 hours if urgent medical need
  • Incomplete submissions: May face delays or automatic denials

Appeals Playbook for Washington

Internal Appeals Process

Level 1 - Redetermination

  • Deadline: 60 days from denial notice
  • Timeline: 7 days for standard, 72 hours for expedited
  • How to file: Written request to Humana with additional documentation

Level 2 - Reconsideration (if applicable)

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for decision

External Review in Washington

After exhausting Humana's internal appeals, Washington residents can request external review through an Independent Review Organization (IRO).

Key Details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to enrollees
  • Timeline: 30 days for standard, 72 hours for urgent
  • Process: Submit request to Washington Insurance Commissioner at 1-800-562-6900

IRO Decision: Binding on Humana if favorable to patient

Common Denial Reasons & Fixes

Denial Reason Fix Strategy Required Documentation
No prior injectable SSA trial Document previous octreotide/lanreotide use Pharmacy records, provider notes
Insufficient response documentation Provide IGF-1 levels before/during treatment Lab reports with dates
Off-label use Submit literature supporting use Peer-reviewed studies, guidelines
Missing specialist requirement Ensure endocrinologist prescribes Provider credentials verification
Incomplete medical necessity Strengthen clinical rationale Detailed letter addressing all criteria

Cost Assistance Options

Manufacturer Support

  • Chiesi Total Care: Patient assistance program
  • Eligibility: Income and insurance-based criteria
  • Contact: chiesitotalcare.com

Additional Resources

  • Medicare Extra Help: Low-income subsidy program
  • State pharmaceutical assistance: Check Washington state programs
  • Foundation grants: Rare disease organizations may offer support

FAQ

How long does Humana prior authorization take for Mycapssa in Washington? Standard decisions come within 72 hours of complete submission. Expedited reviews (for urgent needs) are decided within 24 hours.

What if Mycapssa isn't on Humana's formulary? You can request a formulary exception with medical necessity documentation. Standard timeline is 72 hours for decision.

Can I appeal if Humana denies my Mycapssa request? Yes. Washington residents have robust appeal rights including internal appeals (60-day deadline) and external review through an IRO (180-day deadline from final denial).

Does step therapy apply if I tried injectable SSAs outside Washington? Yes, prior therapy documentation from any location typically satisfies step therapy requirements. Include pharmacy records and provider notes.

What's the difference between expedited and standard appeals? Expedited appeals (72 hours) are for situations where waiting could seriously jeopardize health. Standard appeals (7 days) are for non-urgent situations.

Who can help if I'm struggling with the appeal process? Contact Washington's Insurance Commissioner Consumer Advocacy line at 1-800-562-6900 for free assistance with appeals and complaints.

When patients face complex prior authorization requirements for specialty medications like Mycapssa, Counterforce Health helps by ingesting denial letters and plan policies, then identifying the specific denial basis and drafting targeted rebuttals with the right clinical evidence and procedural requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance plan. Coverage policies and procedures may change. Always verify current requirements with your specific plan and consult official sources for the most up-to-date information.

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