By Counterforce Health Team in Oxlumo (lumasiran) —

How to Get Oxlumo (lumasiran) Covered by Humana in Michigan: Complete Guide with Forms and Appeal Process

Quick Answer: Getting Oxlumo (lumasiran) Covered by Humana in Michigan

Oxlumo requires prior authorization from Humana Medicare Advantage plans. To get approved: (1) Confirm PH1 diagnosis with genetic testing for AGXT mutations, (2) Submit PA request through CenterWell Specialty Pharmacy with urinary oxalate levels and specialist prescription, (3) If denied, file internal appeal within 65 days, then external review with Michigan DIFS within 127 days. Start by calling CenterWell Specialty Pharmacy at 800-486-2668 to initiate the PA process.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Requirements
  3. Submission Process and Portals
  4. What to Do if You're Denied
  5. Michigan External Review Process
  6. Specialty Pharmacy Setup
  7. Support Contacts
  8. Common Questions

1. Verify Your Plan and Find the Right Forms

Before starting the approval process, confirm your specific Humana plan type. Oxlumo (lumasiran) is included on Humana's 2024 Medicare Prior Authorization List under HCPCS code J0224, making prior authorization mandatory.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all Humana Medicare Advantage plans Humana PA List 2024
Specialty Pharmacy Must use CenterWell Specialty Pharmacy CenterWell Specialty
Diagnosis Required Primary hyperoxaluria type 1 (PH1) confirmed FDA labeling requirements
Prescriber Nephrologist or specialist experienced in PH1 Standard payer criteria
Appeals Deadline 65 days for internal, 127 days for Michigan external review Michigan DIFS

2. Prior Authorization Requirements

Humana requires comprehensive documentation to approve Oxlumo coverage. Here's what you need:

Essential Documentation Checklist

  • Genetic confirmation: AGXT gene mutation testing results or liver enzyme analysis confirming PH1
  • Urinary oxalate levels: Recent lab results showing elevated oxalate excretion
  • Specialist prescription: From nephrologist or physician experienced in PH1 management
  • Medical necessity letter: Detailed clinical justification (see clinician requirements below)
  • Weight documentation: For pediatric patients requiring weight-based dosing
  • Prior treatment history: Documentation of conservative management attempts
Clinician Corner: Medical Necessity Letter Requirements

Your letter should include: (1) Confirmed PH1 diagnosis with genetic test results, (2) Current urinary oxalate levels and trend over time, (3) Previous conservative treatments tried (dietary changes, fluid intake), (4) Clinical rationale for Oxlumo based on FDA labeling, (5) Weight-based dosing plan and monitoring schedule, (6) Treatment goals and expected outcomes.

3. Submission Process and Portals

Step-by-Step: Fastest Path to Approval

  1. Contact CenterWell Specialty Pharmacy (800-486-2668) to initiate the prior authorization process
  2. Provider submits PA request via Availity portal with all required documentation
  3. Upload clinical documents including genetic testing, urinary oxalate results, and medical necessity letter
  4. Expect decision within 1-2 business days for electronic submissions, up to 14 days for paper/fax
  5. If approved, CenterWell coordinates delivery and administration scheduling
  6. If denied, proceed immediately to appeals process (see section 4)

Submission Options

Electronic (Fastest)

Fax/Phone

  • Fax PA requests to: 1-877-405-7940
  • Call CenterWell Specialty: 800-486-2668
  • Allow up to 14 days for processing

4. What to Do if You're Denied

If Humana denies your Oxlumo prior authorization, you have multiple appeal options with specific timelines.

Common Denial Reasons and How to Address Them

Denial Reason How to Overturn Documentation Needed
Insufficient PH1 confirmation Submit genetic testing results AGXT mutation analysis or liver enzyme studies
Urinary oxalate not elevated enough Provide recent lab trends Multiple 24-hour urine collections showing elevated oxalate
Non-specialist prescriber Get specialist consultation Nephrologist evaluation and prescription
Lack of medical necessity Strengthen clinical justification Enhanced medical necessity letter with guidelines citations

Internal Appeals Process

Timeline: File within 65 days of denial notice

How to Submit:

  • Call Humana member services: 800-457-4708
  • Submit written appeal via member portal
  • Include all original documentation plus additional supporting evidence

Expected Response: 30 days for pre-service appeals

5. Michigan External Review Process

If Humana upholds the denial after internal appeal, Michigan residents can request an external review through the Department of Insurance and Financial Services (DIFS).

Michigan DIFS External Review

Timeline: 127 days from final internal denial to file with DIFS

How to File:

  1. Complete DIFS External Review Request form online or download PDF
  2. Include copy of final denial letter from Humana
  3. Attach all supporting medical documentation
  4. Submit via online portal, email, fax, or mail

Contact DIFS: 877-999-6442 for guidance

Decision Timeline:

  • Standard review: 60 days maximum
  • Expedited review: 72 hours (requires physician letter stating delay would harm patient)
From Our Advocates

We've seen Michigan external reviews succeed when the submission includes a clear timeline of the patient's clinical deterioration and specific citations to Humana's own policy language. The key is demonstrating that Oxlumo meets the plan's stated criteria, not just general medical necessity.

6. Specialty Pharmacy Setup

Once approved, Oxlumo must be dispensed through CenterWell Specialty Pharmacy, Humana's owned specialty pharmacy network.

CenterWell Onboarding Steps

  1. Provider e-prescribes to CenterWell or calls 800-486-2668
  2. Patient enrollment: Register at CenterWellPharmacy.com using Humana member ID
  3. Benefits verification: CenterWell confirms coverage and copay
  4. Delivery coordination: Schedule monthly loading doses (first 3 months), then quarterly maintenance
  5. Clinical support: Access to pharmacists and case management for ongoing care

Hours: Monday–Friday 8 a.m.–11 p.m., Saturday 8 a.m.–6:30 p.m. ET

7. Support Contacts

Key Phone Numbers

Service Phone Number Hours Purpose
CenterWell Specialty Pharmacy 800-486-2668 Mon–Fri 8–11, Sat 8–6:30 ET PA requests, case management
Humana Member Services 800-457-4708 Mon–Fri 8–8 local time Appeals, coverage questions
Michigan DIFS Consumer Hotline 877-999-6442 Business hours External review guidance
Clinical Pharmacy Review 800-555-CLIN (2546) Business hours PA form questions

When to Call Each Number

  • CenterWell: Start here for all Oxlumo-related requests
  • Humana Member Services: For coverage questions and internal appeals
  • Michigan DIFS: After internal appeal denial, for external review guidance
  • Clinical Pharmacy Review: For questions about required PA documentation

8. Common Questions

How long does Humana prior authorization take for Oxlumo in Michigan? Electronic submissions through Availity typically receive decisions within 1-2 business days. Fax/paper submissions can take up to 14 days.

What if Oxlumo is non-formulary on my Humana plan? Oxlumo requires prior authorization but is covered when medically necessary. Non-formulary status doesn't prevent coverage with proper documentation.

Can I request an expedited appeal in Michigan? Yes. Michigan DIFS offers expedited external review (72-hour decision) when a physician letter confirms that delay would harm the patient's health.

Does step therapy apply to Oxlumo? Typically no. Since Oxlumo is the only FDA-approved siRNA therapy for PH1, step therapy requirements are uncommon. However, documentation of conservative management attempts may be required.

What if I've tried treatments outside Michigan? Prior treatment history from other states is valid. Include all medical records and documentation of previous therapies, regardless of where they were attempted.

How much does Oxlumo cost with Humana coverage? Costs vary by plan. The average annual list price is approximately $493,000, but your out-of-pocket costs depend on your specific Humana plan's specialty drug coverage and annual out-of-pocket maximum.

Getting Oxlumo covered by Humana requires thorough documentation and persistence, but Michigan patients have strong appeal rights if initially denied. Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals that align with each payer's specific criteria.

For ongoing support with insurance approvals and appeals, Counterforce Health's platform ingests denial letters and plan policies to draft point-by-point rebuttals backed by the right clinical evidence and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly. For official Michigan insurance regulations and consumer rights, visit Michigan DIFS.

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