By Counterforce Health Team in Ofev (nintedanib) —

How to Get Ofev (nintedanib) Covered by Humana in Georgia: Prior Authorization Guide and Appeal Templates

Answer Box: Fast Track to Ofev (nintedanib) Coverage

Ofev (nintedanib) requires prior authorization from Humana Medicare Advantage plans. To get approval in Georgia: (1) Have your pulmonologist submit PA with IPF/SSc-ILD diagnosis, HRCT results, and PFT documentation via Humana's provider portal; (2) If denied, file internal appeal within 65 days with medical necessity letter citing ATS/ERS guidelines; (3) Request external review through Georgia Department of Insurance within 60 days if internal appeal fails. Standard PA decisions take 72 hours; appeals typically resolve within 30 days.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana Medicare plans Check your plan's formulary Humana Drug Lists
Formulary Tier Typically Tier 5 (specialty) Plan-specific drug list Humana Formulary Search
Diagnosis Required IPF, SSc-ILD, or progressive fibrosing ILD Medical records with ICD-10 codes FDA Label
Specialist Requirement Pulmonologist attestation preferred Referral or consultation notes Humana PA policy
HRCT Documentation High-resolution CT confirming fibrosis Radiology report Clinical guidelines
PFT Results Pulmonary function tests showing decline Lab/clinic records ATS/ERS Guidelines

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Who does it: You and your healthcare team
Documents needed: Insurance card, recent HRCT report, PFT results from last 6 months, list of prior treatments
Timeline: 1-2 days

2. Pulmonologist Submits Prior Authorization (Clinic)

Who does it: Your prescribing physician or their staff
How to submit: Humana provider portal or fax to plan-specific number
Timeline: 72 hours for standard decision, 24 hours if expedited
Required: Medical necessity statement with diagnosis, progression evidence, treatment rationale

3. Monitor Decision and Prepare for Possible Denial (Patient)

Who does it: You (ask clinic to share decision)
What to watch for: Denial letter with specific reason codes
Timeline: Check after 3 business days
Next step: If denied, immediately begin appeal preparation

4. File Internal Appeal if Denied (Patient + Clinic)

Who does it: You can file, but physician letter is crucial
How to submit: Humana appeals process or call 1-800-833-2364
Timeline: Must file within 65 days of denial notice
Required documents: Enhanced medical necessity letter, clinical guidelines, peer-reviewed studies

5. Request External Review if Internal Appeal Fails (Patient)

Who does it: You
How to submit: Georgia DOI Consumer Portal or call 1-800-656-2298
Timeline: File within 60 days of internal appeal denial
Cost: Free to consumer

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Key Documents
"Diagnosis not confirmed" Submit HRCT report + biopsy (if available) + ICD-10 codes Radiology report, pathology report
"Not medically necessary" Cite ATS/ERS guidelines, show PFT decline ≥10% FVC Clinical guidelines, serial PFTs
"Step therapy not met" Document pirfenidone failure/intolerance or contraindications Treatment history, adverse event notes
"Non-formulary drug" Request formulary exception with comparative effectiveness data Studies showing Ofev superiority for your condition
"Quantity limits exceeded" Justify standard 150mg BID dosing per FDA label FDA prescribing information

Appeals Playbook for Humana in Georgia

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • How to file: Online at Humana member portal, phone 1-800-833-2364, or mail
  • Decision timeline: 7 days standard, 72 hours expedited
  • Required: Written request, enhanced medical documentation, prescriber attestation

External Review (Independent)

  • When eligible: After internal appeal denial or if Humana fails to decide timely
  • Deadline: 60 days from final internal denial in Georgia
  • How to file: Georgia DOI portal or call 1-800-656-2298
  • Decision timeline: 45 days standard, 72 hours expedited for urgent cases
  • Cost: Free to consumer; decision is binding on Humana
From our advocates: We've seen success when patients combine their pulmonologist's clinical letter with peer-reviewed studies specific to their ILD subtype. One patient with SSc-ILD won coverage after including the SENSCIS trial data showing Ofev's efficacy in slowing FVC decline—the external reviewer noted this evidence directly addressed the plan's "experimental" denial reason.

Medical Necessity Letter Checklist

Essential Elements for Your Physician to Include:

Patient Information & Diagnosis

  • Full name, DOB, insurance ID
  • Primary diagnosis with ICD-10 code (J84.10 for IPF, M34.81 for SSc-ILD)
  • Date of diagnosis and confirming tests

Clinical Documentation

  • HRCT findings showing fibrotic changes
  • PFT results demonstrating decline (≥10% FVC reduction preferred)
  • Symptom progression (dyspnea, cough, exercise intolerance)

Treatment History

  • Prior antifibrotic therapies tried and outcomes
  • Reasons for discontinuation (ineffectiveness, adverse events)
  • Contraindications to alternative treatments

Guideline Support

Prescriber Credentials

  • Physician specialty (pulmonology preferred)
  • State license number
  • Contact information for follow-up

Costs & Financial Assistance

Retail Cost: Ofev typically costs $13,000-$15,000 per month without insurance coverage.

Humana Coverage: Most Medicare Advantage plans cover Ofev on formulary tiers 4-5, with copays ranging from $47-$156 per month depending on your plan phase.

Financial Assistance Options:

  • Boehringer Ingelheim CareConnect4Me: Copay assistance up to $1,000/month for eligible patients; enrollment at BI patient portal
  • BI Cares Patient Assistance: Free drug for uninsured patients meeting income criteria
  • Medicare Extra Help: Low-income subsidy reducing Part D costs to $1.55-$4.30 per prescription

Counterforce Health helps patients navigate these complex approval processes by turning insurance denials into targeted, evidence-backed appeals that align with each plan's specific coverage criteria.

When Appeals Fail: Next Steps

If external review doesn't result in coverage, you still have options:

Alternative Medications

  • Esbriet (pirfenidone): The other FDA-approved antifibrotic for IPF; may be preferred on some formularies
  • Off-label immunosuppressants: For SSc-ILD, mycophenolate or cyclophosphamide may be covered

State-Level Complaints

Legal Options

  • Consult healthcare attorney if coverage denial violates state or federal law
  • Consider ERISA attorney for employer-sponsored plans

FAQ: Your Most Common Questions

How long does Humana prior authorization take in Georgia? Standard PA decisions are made within 72 hours. Expedited requests (when delay would seriously jeopardize your health) are decided within 24 hours.

What if Ofev is non-formulary on my Humana plan? Request a formulary exception using Humana's coverage determination form. Your prescriber must provide a supporting statement showing formulary alternatives are ineffective or inappropriate.

Can I request an expedited appeal in Georgia? Yes, if waiting for standard review would seriously jeopardize your health. Check the "expedited" box on appeal forms and have your physician provide a statement explaining the urgency.

Does step therapy apply if I haven't tried pirfenidone? This varies by plan. Some Humana policies require documented trial or contraindication to pirfenidone before approving Ofev. Check your specific plan's coverage criteria.

What happens if I miss the 65-day appeal deadline? Contact Humana immediately to request good cause exception. Valid reasons include not receiving the denial notice or serious illness preventing timely filing.

How much does external review cost in Georgia? External review through Georgia DOI is free to consumers. The decision is binding on your insurance company.

Can Counterforce Health help with my Humana appeal? Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters, plan policies, and clinical notes to create evidence-backed rebuttals that address each plan's specific coverage criteria.

What if my pulmonologist isn't comfortable writing appeals? Provide them with Boehringer Ingelheim's physician appeal letter templates and offer to gather supporting documentation yourself.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and appeals processes. It is not medical advice. Always consult your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. Coverage policies and procedures may change; verify current requirements with your insurer and state regulators.

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