By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (Nivolumab) Covered by Humana in Texas: Complete Prior Authorization Guide

Answer Box: Getting Opdivo (Nivolumab) Covered by Humana in Texas

Opdivo requires prior authorization for all Humana Medicare Advantage plans in Texas. Your oncologist must submit documentation including pathology reports, biomarker testing, and prior treatment history through Humana's provider portal or by fax to 877-486-2621. Standard decisions take 30 days; expedited reviews (72 hours) are available for urgent cases by calling 800-867-6601. If denied, you have 65 days to file an appeal and can request external review through the Texas Department of Insurance.

First step: Contact your oncologist today to confirm they have complete staging, biomarker results, and treatment history ready for submission.

Table of Contents

  1. Before You Start: Coverage Verification
  2. What Documentation You Need
  3. How to Submit the Prior Authorization
  4. Timeline and Follow-Up
  5. If You Need More Information
  6. If Your Request is Denied
  7. Appeals Process in Texas
  8. Costs and Financial Assistance
  9. FAQ
  10. Quick Reference Checklist

Before You Start: Coverage Verification

Confirm Your Plan Type

Opdivo requires prior authorization for all Humana Medicare Advantage HMO and PPO plans in Texas. The drug is covered under your medical benefit (Part B), not pharmacy benefit (Part D), since it's administered by IV infusion in clinical settings.

Note: If you have a Medicare Supplement plan or MA PFFS plan, different rules may apply. Verify with Humana member services at 800-457-4708.

Check Your Network Status

Ensure your oncologist and infusion center are in-network with your Humana plan. Out-of-network providers may require additional authorization steps or result in higher out-of-pocket costs.

Verify Formulary Coverage

Opdivo is listed on Humana's 2024-2026 medication prior authorization lists for MA plans. Both the standard IV formulation and the newer subcutaneous version (Opdivo Qvantig) require prior authorization.

What Documentation You Need

Your oncologist's office must gather comprehensive clinical documentation to demonstrate medical necessity:

Essential Clinical Information

Document Type What's Required Where to Get It
Pathology Reports Complete histology, tumor markers Hospital/lab that performed biopsy
Biomarker Testing PD-L1 expression, ALK status (for NSCLC) Molecular pathology lab
Staging Information Current TNM staging, imaging results Radiology reports, oncology notes
Prior Treatment History Previous therapies tried, outcomes, dates Medical records, pharmacy records
Diagnosis Codes Correct ICD-10 codes for your cancer type Oncologist's billing department

Medical Necessity Letter Components

Your oncologist should include:

  • FDA-approved indication for your specific cancer type
  • Why Opdivo is appropriate for your disease stage
  • Documentation of prior treatment failures or contraindications
  • Clinical rationale based on FDA labeling
  • Treatment goals and monitoring plan

How to Submit the Prior Authorization

  1. Your provider accesses Humana's provider portal
  2. Uses the prior authorization search tool to find Opdivo requirements
  3. Completes the electronic form with all required documentation
  4. Submits digitally for fastest processing

Fax Submission

General Medicare Rx requests: 877-486-2621

Texas-specific form: Use the dedicated Texas authorization form for professionally administered drugs (verify current form with your provider)

Phone Support

Call 866-421-5663 (Monday-Friday, 7am-7pm CT) for:

  • Status updates on pending requests
  • Clarification of requirements
  • Technical support with portal submission

Timeline and Follow-Up

Standard Processing Times

  • Standard decisions: 30 calendar days for Part B medical services
  • Expedited reviews: 72 hours if delay could seriously harm your health
  • Complete electronic submissions: 95% processed within one business day

When to Follow Up

Call Humana at 800-867-6601 if:

  • No response after 15 days (standard request)
  • No response after 48 hours (expedited request)
  • You receive a request for additional information

Sample Follow-Up Script

"Hi, I'm calling to check the status of a prior authorization request for Opdivo for [patient name], member ID [number]. The request was submitted on [date]. Can you provide an update and reference number for my records?"

If You Need More Information

Humana may request additional documentation during review. Common requests include:

  • More recent imaging: Updated scans showing disease progression
  • Biomarker clarification: Additional testing results or lab reports
  • Treatment timeline: Detailed chronology of prior therapies and outcomes
  • Peer-to-peer review: Direct discussion between Humana's medical director and your oncologist
Tip: Respond to information requests within 14 days to avoid automatic denial. Keep copies of everything you submit.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Insufficient biomarker data Submit complete PD-L1 expression testing results
Wrong line of therapy Document prior treatment failures with dates and outcomes
Off-label use Provide clinical literature supporting off-label indication
Incomplete staging Submit current imaging and pathology reports
Missing medical necessity Request peer-to-peer review with medical director

Request a Peer-to-Peer Review

Before filing an appeal, ask your oncologist to request a peer-to-peer review. This allows direct discussion between your doctor and Humana's medical director, often resolving denials without formal appeals.

Appeals Process in Texas

Internal Appeal (First Level)

Timeline: You have 65 days from the denial notice to file an internal appeal

How to file:

  • Online through Humana member portal
  • Mail to address on your denial notice
  • Fax using the number provided in your denial letter

Decision timeline:

  • Standard: 7 calendar days for Part D, 30 days for Part C
  • Expedited: 72 hours if medically urgent

External Review (Texas Department of Insurance)

If Humana upholds the denial, Texas law provides independent external review through the Texas Department of Insurance.

Key points:

  • Available when denial is based on medical necessity
  • Must file within 4 months of final internal denial
  • Humana pays for the review
  • Decision is binding on Humana
  • Standard reviews decided within 20 days
  • Urgent cases decided within 5 days

Contact for help:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
From our advocates: We've seen successful appeals when families gathered all their medical records upfront and worked closely with their oncologist to document exactly why alternatives weren't suitable. The key is showing Humana's own medical policies support coverage for your specific situation.

Costs and Financial Assistance

Expected Out-of-Pocket Costs

With Humana Medicare Advantage, you typically pay:

  • 20% coinsurance after meeting your annual deductible
  • For a $7,943 vial, this equals approximately $1,589 per dose

Financial Assistance Options

Bristol Myers Squibb Patient Assistance:

  • Access Support program
  • May reduce copays for eligible patients
  • Income-based assistance available

Medicare Extra Help:

  • Low-income subsidy program
  • Can significantly reduce drug costs
  • Apply at ssa.gov

FAQ

Q: How long does Humana prior authorization take for Opdivo in Texas? A: Standard requests take up to 30 days. Expedited requests for urgent medical situations are decided within 72 hours. Electronic submissions through the provider portal are typically processed within one business day.

Q: What if Opdivo isn't on Humana's formulary? A: Opdivo requires prior authorization but is covered under medical benefits for FDA-approved indications. You can request a formulary exception if coverage is denied.

Q: Can I request an expedited appeal in Texas? A: Yes. Call 800-867-6601 to request expedited review if delays could seriously jeopardize your health. Both internal appeals and external reviews can be expedited.

Q: Does Humana require step therapy for Opdivo? A: Requirements vary by indication. For some cancers, you may need to try other treatments first unless contraindicated. Your oncologist can request step therapy exceptions.

Q: What happens if I miss the 65-day appeal deadline? A: Missing this deadline forfeits your right to appeal. Set a reminder for 50 days after denial to ensure adequate preparation time.

Q: Can I get help with the appeals process in Texas? A: Yes. Contact the Texas Department of Insurance (1-800-252-3439) or Office of Public Insurance Counsel (1-877-611-6742) for free assistance with appeals.

Quick Reference Checklist

Before Submitting:

  • Verify Humana plan type and network status
  • Gather complete pathology reports
  • Obtain biomarker testing results
  • Document all prior treatments and outcomes
  • Collect current staging/imaging reports
  • Confirm correct ICD-10 diagnosis codes

Submission:

  • Use provider portal for fastest processing
  • Include medical necessity letter with FDA indication
  • Attach all supporting documentation
  • Request expedited review if urgent
  • Keep copies and reference numbers

Follow-Up:

  • Call for status after 15 days (standard) or 48 hours (expedited)
  • Respond to information requests within 14 days
  • Consider peer-to-peer review before appeal
  • File appeal within 65 days if denied

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals through targeted, evidence-backed strategies. Our platform analyzes denial letters, plan policies, and clinical notes to create point-by-point rebuttals that align with each insurer's specific requirements, helping patients, clinicians, and specialty pharmacies navigate complex prior authorization processes more effectively.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or a guarantee of coverage. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance plan. Coverage policies and procedures may change.

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