By Counterforce Health Team in Pemazyre (pemigatinib) —

How to Get Pemazyre (Pemigatinib) Covered by Humana in New York: Complete Forms, Appeals, and Support Guide

Quick Answer: Getting Pemazyre Covered by Humana in New York

Pemazyre (pemigatinib) requires prior authorization from Humana in New York. Key requirements: FGFR2 fusion testing report, baseline eye exam, and treatment history documentation. Submit via Humana's provider portal or fax to 877-486-2621. Standard approval takes 7 days; expedited reviews available within 72 hours for urgent cases. If denied, you have 65 days to appeal internally, then 180 days for New York State external review. Start today: Verify your plan's formulary status and gather required documentation.

Table of Contents

Verify Your Plan and Find the Right Forms

Before starting your Pemazyre prior authorization, confirm your specific Humana plan type and coverage details:

Coverage Status for 2025:

  • Pemazyre is on most Humana Medicare formularies but requires prior authorization
  • Quantity limit: typically 28 tablets per 28 days
  • Tier placement varies by specific plan (usually specialty tier)
Note: Medicare Advantage and standalone Part D plans may have slightly different requirements. Always verify with your specific plan documents.

Plan Verification Steps:

  1. Call Humana Member Services at 1-800-457-4708
  2. Use the Humana prior authorization search tool
  3. Check your plan's current formulary document

Required Forms and Documentation

Essential Documentation Checklist

Medical Documentation:

  • ✅ FGFR2 fusion testing report - Complete pathology showing FGFR2 fusion or rearrangement
  • ✅ Baseline ophthalmology exam - Required due to retinal toxicity risk
  • ✅ Treatment history - Prior therapies tried, failed, or contraindicated
  • ✅ Clinical notes - Supporting cholangiocarcinoma diagnosis with ICD-10 codes

Administrative Forms:

  • ✅ Humana Medicare prior authorization form (plan-specific)
  • ✅ Prescriber attestation of medical necessity
  • ✅ Patient insurance information and member ID
Tip: Missing FGFR2 fusion documentation is the most common cause of delays. Ensure your pathology report clearly states the specific FGFR2 alteration.

Medical Necessity Letter Requirements

Your prescriber's letter should include:

  1. Diagnosis: Unresectable/metastatic cholangiocarcinoma with documented FGFR2 fusion
  2. Prior treatments: Specific therapies tried and outcomes
  3. Clinical rationale: Why Pemazyre is appropriate at this stage
  4. Monitoring plan: Ophthalmology follow-up schedule
  5. Dosing justification: Based on patient weight/BSA if applicable

Submission Portals and Methods

Primary Submission Options

1. Humana Provider Portal (Preferred)

  • Electronic submission for fastest processing
  • Real-time status tracking
  • Automatic confirmation receipts
  • Access: provider.humana.com

2. Fax Submission

  • Prior authorization fax: 877-486-2621
  • Include cover sheet with member ID and prescriber information
  • Retain fax confirmation for records

3. Mail Submission

  • Use address provided on your plan's PA form
  • Send via certified mail for tracking
  • Allow additional processing time

Upload Requirements

  • PDF format preferred for all documents
  • Maximum file size: typically 10MB per document
  • Clear, legible scans of all supporting materials

Specialty Pharmacy Network

Pemazyre is typically dispensed through Humana's specialty pharmacy network:

CenterWell Specialty Pharmacy (Primary)

  • Integrated with Humana systems
  • Patient support services included
  • Direct billing to insurance

Network Onboarding Steps:

  1. Prescriber sends e-prescription to specialty pharmacy
  2. Pharmacy initiates prior authorization process
  3. Patient receives outreach for coordination
  4. Delivery arranged upon approval
Important: Using out-of-network specialty pharmacies may result in higher costs or coverage denials.

Support Lines and Contacts

Humana Contact Information

Contact Type Phone Number Purpose Hours
Member Services 1-800-457-4708 Coverage questions, status checks M-F 8am-8pm
Provider Services 1-800-448-6262 PA submissions, peer-to-peer M-F 8am-6pm
Pharmacy Help Desk 1-800-281-6918 Formulary questions, exceptions 24/7

What to Ask When Calling

  • "What's the status of PA request for member [ID]?"
  • "Can you confirm FGFR2 testing documentation was received?"
  • "Is an expedited review available for this case?"
  • "What additional documentation is needed?"

New York Appeals Process

If your Pemazyre request is denied, New York offers strong patient protection through a multi-level appeals process:

Level 1: Internal Appeal (Humana)

  • Deadline: 65 days from denial notice
  • Timeline: 30 days standard, 72 hours expedited
  • How to file: Use appeal form included with denial letter
  • Required: All original documentation plus any new supporting evidence

Level 2: External Review (New York State)

  • Deadline: 180 days from final internal denial
  • Timeline: 30 days standard, 72 hours urgent
  • Agency: New York Department of Financial Services
  • Contact: 888-990-3991 (urgent appeals)
  • Fax: 800-332-2729

External Review Success Rate: Approximately 45% of appeals overturn insurance denials in New York.

Getting Help with Appeals

Community Health Advocates (CHA)

  • Phone: (888) 614-5400
  • Email: [email protected]
  • Hours: Monday-Friday, 9am-4pm
  • Services: Free assistance with filing appeals, gathering documentation, and understanding your rights

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
No FGFR2 testing documented Submit complete pathology report FGFR2 fusion/rearrangement confirmation
Missing eye exam Provide ophthalmology consultation Baseline exam + monitoring plan
Step therapy not completed Document contraindications/failures Prior treatment records
Quantity limit exceeded Justify dosing based on guidelines Clinical rationale for dose/frequency
Not medically necessary Strengthen clinical justification Updated medical necessity letter

Cost Assistance Programs

Manufacturer Support

IncyteCARES Patient Assistance Program

  • Income-based assistance for eligible patients
  • Note: Medicare patients cannot use manufacturer copay cards
  • Application: Contact Incyte directly or ask your prescriber's office

Medicare Cost Protections

  • 2025 Medicare Part D out-of-pocket cap: $2,000 annually
  • Catastrophic coverage applies after reaching threshold
  • Low Income Subsidy (Extra Help) available for qualifying patients

When to Contact State Regulators

Contact New York regulators if you experience:

  • Unreasonable delays in processing (beyond stated timelines)
  • Failure to provide required appeal forms
  • Denial of expedited review for urgent medical needs

New York Department of Financial Services

  • Consumer hotline: 1-800-342-3736
  • Online complaints: dfs.ny.gov
  • External appeals: 888-990-3991

FAQ

How long does Humana prior authorization take in New York? Standard review: 7 days. Expedited review: 72 hours if medical urgency is documented.

What if Pemazyre isn't on my formulary? File a formulary exception request with medical necessity documentation. Include evidence that formulary alternatives are inappropriate.

Can I get an expedited appeal? Yes, if your doctor certifies that delays would jeopardize your health. Mark all forms as "urgent" and provide clinical justification.

Does step therapy apply to Pemazyre? Humana may require trial of other therapies first. Document any contraindications or prior failures to bypass step therapy.

What happens if I'm already taking Pemazyre? Continue taking it while appeals are pending. Coverage typically continues during the review process.

How much will Pemazyre cost with Humana? Costs depend on your specific plan and tier placement. Specialty tier copays typically range from $47-$150 per month for Medicare Part D.

Can I use a copay card with Medicare? No, federal law prohibits manufacturer copay assistance for Medicare patients. Look into patient assistance programs instead.

What if my appeal is denied? You can request external review through New York State DFS within 180 days of the final denial.

Update Frequency

Insurance policies and forms change regularly. Check for updates:

  • Quarterly: Formulary changes and coverage policies
  • Annually: New PA forms and submission requirements
  • As needed: Appeals processes and contact information

For the most current information, always verify directly with Humana's provider portal or member services.

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance plan for personalized guidance.

Sources & Further Reading

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