By Counterforce Health Team in Ofev (nintedanib) —

How to Get Ofev (nintedanib) Covered by Humana in Ohio: Forms, Appeals, and Contact Numbers

Answer Box: Getting Ofev (nintedanib) Covered by Humana in Ohio

Ofev (nintedanib) requires prior authorization from Humana in Ohio. Your pulmonologist must submit clinical documentation through Humana's online portal or by fax to 877-486-2621. Required evidence includes HRCT confirming fibrosis, pulmonary function tests showing decline, and specialist attestation for idiopathic pulmonary fibrosis or progressive interstitial lung disease. If denied, you have 65 days for internal appeals and 180 days for external review through the Ohio Department of Insurance. Start today: Verify your Humana plan covers Ofev, gather your clinical records, and have your pulmonologist submit the PA request with complete documentation.

Table of Contents

  1. Verify Your Plan Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Specialty Pharmacy Setup
  5. Support Phone Numbers
  6. Appeals Process in Ohio
  7. State Resources and External Review
  8. Common Denial Reasons and Solutions
  9. Costs and Financial Assistance
  10. FAQ

Verify Your Plan Coverage

Before starting the prior authorization process, confirm that your specific Humana plan in Ohio covers Ofev (nintedanib). Ofev is typically classified as a Tier 5 specialty drug on Medicare Advantage and Part D formularies, which means higher cost-sharing for patients.

Coverage Verification Steps:

  1. Check your formulary: Log into your Humana member portal or call member services at 1-800-833-2364
  2. Confirm specialty pharmacy requirement: Ofev must be filled through Humana's approved specialty pharmacy network
  3. Review prior authorization status: Most Humana plans require PA for Ofev regardless of indication
Note: Coverage and restrictions may change annually. Always recheck your formulary each plan year, even if you're currently taking Ofev.

Prior Authorization Forms and Requirements

Required Clinical Documentation

Your pulmonologist must provide comprehensive clinical evidence supporting your Ofev prescription. Here's what Humana typically requires:

Essential Documentation:

  • High-resolution computed tomography (HRCT) scan confirming pulmonary fibrosis
  • Pulmonary function tests (PFTs) showing forced vital capacity (FVC) decline
  • Specialist (pulmonologist) attestation and clinical notes
  • Confirmed diagnosis with appropriate ICD-10 codes
  • Documentation of FDA-approved indication (IPF, SSc-ILD, or progressive fibrosing ILD)

Additional Requirements May Include:

  • Previous treatment history and failures/contraindications
  • Baseline liver function tests (Ofev requires hepatic monitoring)
  • Patient's weight and dosing rationale (standard 150 mg twice daily with food)
  • Treatment goals and monitoring plan

Medical Necessity Letter Checklist

When your pulmonologist writes the medical necessity letter, ensure it includes:

✓ Problem statement: Clear diagnosis with supporting imaging/biopsy results
✓ Disease progression: PFT trends showing FVC decline over time
✓ Prior treatments: Other therapies tried, failed, or contraindicated
✓ Clinical rationale: Why Ofev is appropriate based on FDA labeling and guidelines
✓ Dosing justification: Standard 150 mg BID or dose reduction rationale
✓ Monitoring plan: Regular PFTs, liver function tests, and adverse event management

Submission Portals and Methods

Humana Provider Portal: Providers can submit PA requests electronically through Humana's online system. This method typically provides faster processing and automatic confirmation receipts.

Fax Submission

Fax number: 877-486-2621
Required: Complete Humana-specific prior authorization form with all supporting clinical documentation

Phone Support for Providers

Humana Clinical Pharmacy Review: 1-800-555-CLIN (2546)
Hours: Monday–Friday, 8 a.m.–8 p.m. local time
Use for: PA submission assistance, status checks, and clinical questions

Tip: Always obtain a reference number when submitting by phone or fax. This helps track your request and expedite follow-up calls.

Specialty Pharmacy Setup

Ofev must be dispensed through Humana's approved specialty pharmacy network. You cannot fill this prescription at regular retail pharmacies.

Approved Specialty Pharmacies for Ofev

Humana Specialty Pharmacy
Phone: (855) 425-3994
Fax: (855) 201-4396

KSP Specialty Pharmacy (McLaren)
Added to Humana network as of May 1, 2023

Other Network Options:

  • Accredo Specialty Pharmacy
  • Optum Specialty Pharmacy
  • Orsini Healthcare

Enrollment Process

  1. Provider completes Ofev prescription form with patient and insurance information
  2. Select preferred specialty pharmacy from approved network
  3. Fax completed form to chosen pharmacy with copies of insurance cards
  4. Pharmacy coordinates PA submission and insurance verification
  5. Patient receives enrollment call to set up delivery and counseling

Prescription Transfer

If you're already taking Ofev and need to transfer to a Humana-approved pharmacy:

  1. Contact your new specialty pharmacy directly
  2. Provide current prescription information and insurance details
  3. New pharmacy will coordinate transfer with your previous pharmacy
  4. Ensure continuous supply during transition period

Support Phone Numbers

For Patients (Members)

Humana Member Services: 1-800-833-2364
Use for: Coverage verification, claim status, appeals assistance

Humana Medicare Members: Check your member ID card for plan-specific number

For Providers

Provider Contact Center (Medicare): 1-800-457-4708
Clinical Intake Team: 1-800-523-0023 (24/7 for medical PAs)
Pharmacy Prior Authorization: 1-800-555-CLIN (2546)

Case Management and Escalation

For complex cases or urgent situations, providers can request:

  • Peer-to-peer review: Clinical discussion between prescriber and Humana medical director
  • Expedited review: For urgent medical situations (typically 72 hours)
Important: When calling, have patient information ready (member ID, date of birth, requested service, and clinical details).

Appeals Process in Ohio

If Humana denies your Ofev prior authorization, you have specific appeal rights under Ohio law and Medicare regulations.

Internal Appeals Timeline

First Level Appeal

  • Deadline: 65 days from denial notice
  • Decision timeframe: 30 days for standard, 72 hours for expedited
  • How to file: Online portal, phone, or written request

Second Level Appeal (if applicable)

  • Deadline: 65 days from first-level denial
  • Decision timeframe: 30 days for standard, 72 hours for expedited

External Review in Ohio

If Humana upholds the denial after internal appeals, Ohio residents can request an independent external review.

Key Details:

  • Filing deadline: 180 days from final internal denial
  • Review timeline: 30 days for standard, 72 hours for expedited
  • Decision authority: Independent Review Organization (IRO) assigned by Ohio Department of Insurance
  • Binding result: IRO decision is final and binding on Humana

How to Request External Review

  1. Submit written request to Humana (they forward to Ohio DOI)
  2. Include supporting documentation not previously submitted
  3. Specify urgency if expedited review needed
  4. Ohio DOI assigns IRO with appropriate medical expertise
  5. IRO reviews case and issues binding decision

State Resources and External Review

Ohio Department of Insurance

Consumer Services Division
Phone: 1-800-686-1526
Use for: External review questions, appeal assistance, regulatory complaints

Online Resources: The ODI website provides external review request forms and detailed instructions for Ohio residents.

Additional Ohio Resources

UHCAN Ohio (Universal Health Care Action Network)
Nonprofit advocacy group providing consumer assistance with insurance appeals and coverage issues.

OSHIIP (Ohio Senior Health Insurance Information Program)
Helps with Medicare-related issues, though ODI handles most under-65 appeals.

Note: Self-funded employer plans follow federal ERISA law rather than Ohio's external review process, but many voluntarily provide similar protections.

Common Denial Reasons and Solutions

Denial Reason Required Documentation How to Address
No specialist attestation Pulmonologist evaluation and prescription Ensure prescriber is board-certified pulmonologist
Insufficient imaging HRCT scan confirming fibrosis Submit complete radiology report with fibrosis findings
Missing PFT data Pulmonary function tests showing decline Provide baseline and follow-up PFTs demonstrating FVC decline
Diagnosis not confirmed Clear ICD-10 coding for IPF or qualifying ILD Ensure diagnosis matches FDA-approved indications
Step therapy required Documentation of prior therapy failures Submit records of previous treatments and outcomes
Quantity limits exceeded Clinical justification for dosing Provide rationale for standard 150 mg BID or dose adjustments

Strengthening Your Appeal

When appealing a denial, include:

  • Updated clinical notes showing disease progression
  • Peer-reviewed literature supporting Ofev use for your condition
  • Guidelines from professional societies (American Thoracic Society, etc.)
  • Comparative effectiveness data if step therapy is required

Costs and Financial Assistance

Out-of-Pocket Costs

Ofev typically costs $13,000-$15,000 for a 30-day supply without insurance. With Humana coverage, your cost depends on:

  • Plan type: Medicare Advantage vs. Part D
  • Formulary tier: Usually Tier 5 specialty
  • Deductible status: Whether you've met annual deductible
  • Coverage gap: Medicare "donut hole" considerations

Financial Assistance Programs

Boehringer Ingelheim CareConnect4Me

  • Copay assistance for eligible patients
  • Bridge program for coverage delays
  • Patient assistance for uninsured/underinsured

BI Cares Foundation

  • Need-based assistance program
  • Income and insurance requirements apply
Tip: Enroll in manufacturer programs early in the year to maximize benefits, especially if you'll hit Medicare's coverage gap.

FAQ

How long does Humana prior authorization take for Ofev in Ohio?
Standard PA decisions typically take 3-5 business days. Expedited requests for urgent medical situations are processed within 72 hours.

What if Ofev is non-formulary on my Humana plan?
You can request a formulary exception by demonstrating medical necessity and providing clinical documentation. The process is similar to standard PA but may require additional justification.

Can I request an expedited appeal if my condition is worsening?
Yes. If your pulmonologist certifies that a delay would seriously jeopardize your health, you can request expedited internal and external reviews with 72-hour decision timelines.

Does step therapy apply if I've already tried other treatments outside Ohio?
Previous treatment history from other states should be accepted. Provide complete medical records documenting prior therapies, failures, and contraindications.

What happens if I move to Ohio while taking Ofev?
Contact Humana member services immediately to update your address and confirm continued coverage. You may need to transfer to an Ohio-approved specialty pharmacy.

How often do I need to renew prior authorization?
PA approval periods vary by plan, typically 6-12 months. Your specialty pharmacy will notify you when renewal is needed and coordinate with your prescriber.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes like Ofev approvals. The platform analyzes denial letters, identifies specific coverage criteria, and drafts targeted appeals with the right clinical evidence and regulatory requirements. By automating much of the appeals process, Counterforce Health reduces the administrative burden on healthcare providers while improving approval rates for patients who need specialty medications.

For complex cases involving multiple denials or unusual circumstances, consider working with experienced advocates who understand both Humana's specific requirements and Ohio's regulatory landscape. The combination of proper clinical documentation, timely submission, and persistent advocacy significantly improves your chances of getting Ofev covered.

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 directly and consult with your healthcare provider about treatment decisions. For official Ohio insurance regulations, visit the Ohio Department of Insurance website.

Sources & Further Reading

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