By Counterforce Health Team in Myozyme (alglucosidase alfa) —

How to Get Myozyme (Alglucosidase Alfa) Covered by Humana in Texas: Complete Guide to Forms, Appeals & Approval

Answer Box: Getting Myozyme Covered by Humana in Texas

Fastest path to approval: Humana requires prior authorization for Myozyme (alglucosidase alfa) using HCPCS code J0221. Your doctor submits the request via Humana's provider portal, by fax to 877-486-2621, or by calling 800-555-CLIN (2546). Include confirmed Pompe disease diagnosis, genetic/enzyme testing, and specialist documentation. If denied, you have 65 days to appeal through Medicare's federal process (not Texas TDI). Start today: Ask your prescriber to check Humana's formulary and begin the prior authorization request with complete diagnostic documentation.

Table of Contents

Verify Your Plan and Find the Right Forms

Before starting your Myozyme prior authorization, confirm your exact Humana plan type. This determines which forms and processes apply:

Medicare Advantage/Part D Plans: Most Humana members in Texas have Medicare Advantage plans that include prescription drug coverage. These follow federal Medicare rules for appeals and external review.

Commercial Plans: Less common but follow different prior authorization workflows and may be subject to Texas state insurance regulations.

Tip: Call the number on your Humana member ID card to verify your plan type and current formulary status for Myozyme.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required (HCPCS J0221) Humana PA List
Formulary Status Check current tier placement Humana Drug Lists
Diagnosis Documentation Confirmed Pompe disease FDA label, genetic/enzyme testing
Specialist Requirement Often required for approval Metabolic or genetic specialist
Appeal Deadline 65 days from denial Medicare Appeals Process

Required Forms for Prior Authorization

Primary Forms

Request for Medicare Prescription Drug Coverage Determination

  • Used for all Part D medication requests including Myozyme
  • Available through Humana's provider portal
  • Must include HCPCS code J0221 and corresponding NDC

Medical Necessity Documentation Your prescriber should include:

  • Confirmed Pompe disease diagnosis with ICD-10 codes
  • Genetic testing results or enzyme activity levels
  • Previous treatment history and outcomes
  • Current clinical status and treatment goals
  • Dosing rationale (typically 20 mg/kg every 2 weeks)
Note: For professionally administered drugs like Myozyme, additional forms may be required through the medical benefit rather than pharmacy benefit.

Submission Portals and Methods

Online Submission

Humana Provider Portal

  • Primary method for most prior authorization requests
  • Allows document upload and status tracking
  • Access at provider.humana.com

Availity Integration

  • Many Humana prior authorizations process through Availity
  • Requires separate account setup
  • Electronic submission with faster processing

Phone and Fax Options

Humana Clinical Pharmacy Review (HCPR)

  • Phone: 800-555-CLIN (2546)
  • Hours: Monday-Friday, 8 a.m.-8 p.m. local time
  • Fax: 877-486-2621

For Professionally Administered Drugs

  • Fax to Medication Intake Team: 888-447-3430
  • Include all supporting clinical documentation

Specialty Pharmacy Setup

CenterWell Specialty Pharmacy

Humana partners with CenterWell for specialty medications like Myozyme:

Provider Contact: 800-486-2668 Hours: Monday-Friday, 8 a.m.-8 p.m.; Saturday, 8 a.m.-6 p.m. (Eastern)

Setup Process:

  1. Prior authorization approval required first
  2. CenterWell coordinates with your prescriber
  3. Home delivery or clinic administration arranged
  4. Patient education and monitoring support provided

Transfer Instructions

If switching from another specialty pharmacy:

  • Contact CenterWell with current pharmacy information
  • Provide remaining refills and prescription details
  • Allow 3-5 business days for transfer completion

Support Lines and Contacts

For Providers

Clinical Pharmacy Review: 800-555-CLIN (2546)

  • Prior authorization requests and status
  • Step therapy exceptions
  • Quantity limit appeals

General Provider Services: 800-457-4708

  • Medical and pharmacy preauthorizations
  • Available 7 days a week, 8 a.m.-8 p.m. Eastern

Expedited Decisions: 866-737-5113

  • For urgent coverage decisions
  • Use when delay would jeopardize patient health

For Members

Customer Care: Number on your Humana member ID card

  • Coverage questions and status updates
  • Appeals assistance and forms
  • Available during standard business hours

Texas Appeals Process

Important: Medicare vs. State Rules

Medicare Advantage Plans (most Humana members): Follow federal Medicare appeals process, NOT Texas Department of Insurance external review.

Commercial Plans: May use Texas TDI Independent Review Organization (IRO) process.

Medicare Appeals Timeline

  1. Reconsideration (Level 1): File within 65 days of denial
  2. Independent Review Entity: Automatic if Level 1 denied
  3. Administrative Law Judge: For higher dollar amounts
  4. Medicare Appeals Council
  5. Federal District Court

Response Times:

  • Standard appeals: 7 calendar days
  • Expedited appeals: 72 hours

Required Documentation for Appeals

  • Original denial letter
  • Complete medical records supporting Pompe diagnosis
  • Prescriber letter of medical necessity
  • Genetic testing or enzyme activity results
  • Documentation of specialist care
From our advocates: In our experience with rare disease appeals, the most successful cases include comprehensive diagnostic documentation from the initial request. Patients who work closely with metabolic specialists and include both genetic testing results and clinical progression notes see faster approvals than those with incomplete diagnostic workups.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Diagnosis not confirmed Submit genetic testing, enzyme levels, specialist evaluation
Dosing outside guidelines Provide FDA labeling, weight-based calculations, specialist rationale
Lack of specialist involvement Transfer care to or consult with metabolic/genetic specialist
Insufficient prior therapy documentation Document any previous treatments, outcomes, contraindications
Administrative errors Resubmit with correct codes (J0221), patient information, prescriber NPI

Costs and Financial Assistance

Manufacturer Support

Sanofi Patient Assistance Programs

  • Copay assistance for eligible patients
  • Income-based free drug programs
  • Contact: Sanofi patient support (verify current programs)

Foundation Grants

  • National Organization for Rare Disorders (NORD)
  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
Note: Assistance program availability and eligibility change frequently. Contact programs directly for current requirements.

FAQ

Q: How long does Humana prior authorization take for Myozyme? A: Standard decisions within 30 days for pre-service requests. Expedited reviews available within 72 hours for urgent cases.

Q: What if Myozyme is not on Humana's formulary? A: Request a formulary exception with medical necessity documentation. Your prescriber must demonstrate why Myozyme is medically necessary compared to formulary alternatives.

Q: Can I get an expedited appeal in Texas? A: Yes, for Medicare Advantage plans. Request expedited review if waiting would seriously jeopardize your health. Decision required within 72 hours.

Q: Does step therapy apply to Myozyme? A: Rarely, since Myozyme is typically first-line therapy for infantile-onset Pompe disease. However, Humana may require documentation that other enzyme replacement therapies are inappropriate.

Q: What happens if my appeal is denied? A: For Medicare plans, your case automatically goes to an Independent Review Entity (IRE). For commercial plans, you may request Texas TDI external review within 4 months.

Q: Can a family member help with my appeal? A: Yes, using Humana's Appointment of Authorized Representative form or appropriate legal documentation.

When navigating complex prior authorization and appeals processes, platforms like Counterforce Health can help by analyzing denial letters, identifying specific policy requirements, and drafting targeted appeals with the right clinical evidence and procedural compliance. Their system is designed to turn insurance denials into successful approvals by aligning appeals with each payer's specific rules and documentation requirements.

Update Cadence

Check quarterly: Humana formulary changes, prior authorization lists, and contact numbers can change with each plan year or quarterly updates.

Monitor annually: Medicare plan benefits, appeal procedures, and Texas insurance regulations may be updated each January.

Stay current: Bookmark Humana's provider portal and Medicare.gov appeals page for the latest forms and procedures.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures change frequently. Always verify current requirements with Humana and consult with your healthcare provider for medical decisions. For personalized assistance with Texas insurance issues, contact the Texas Department of Insurance at 1-800-252-3439 or visit tdi.texas.gov.

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