By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

How to Get Photrexa Covered by Humana in California: Prior Authorization Guide & Appeals Process

Answer Box: Getting Photrexa Covered by Humana in California

Photrexa (riboflavin ophthalmic solution) is covered by Humana Medicare Advantage plans in California, but prior authorization is required. The fastest path to approval: (1) Your eye doctor submits a PA request with progression documentation (Kmax increase ≥1.0 D or pachymetry thinning ≥10 microns), (2) Use CPT 0402T and HCPCS J2787 codes, (3) If denied, file an internal appeal within 65 days. California residents can escalate to Independent Medical Review (IMR) through the Department of Managed Health Care if the internal appeal fails.

Table of Contents

Plan Types & Coverage Implications

Humana operates primarily Medicare Advantage plans in California, which means your Photrexa coverage falls under Medicare Part D prescription drug benefits with additional managed care requirements.

Key Coverage Rules:

  • Prior authorization mandatory for corneal cross-linking procedures using Photrexa
  • Network restrictions apply - procedure must be performed by in-network ophthalmologists
  • Step therapy may be required depending on your specific plan
  • Age requirements: Generally covered for patients 14-65 years old with progressive keratoconus

Unlike traditional Medicare, Humana Medicare Advantage plans use utilization management to control costs, which means more paperwork but also more structured appeal rights.

Formulary Status & Tier Placement

Photrexa is covered under Humana's medical benefit (not pharmacy benefit) when used with the iLink® system for FDA-approved epithelium-off corneal cross-linking. This is critical because:

  • Medical vs. Pharmacy Coverage: The drug is covered as part of a procedure, not as a standalone prescription
  • No Traditional Formulary Tier: Coverage depends on meeting medical necessity criteria rather than formulary placement
  • Only FDA-Approved Method Covered: Epithelium-off technique only; epithelium-on (epi-on) CXL is considered experimental
Note: Alternative treatments like specialty contact lenses or INTACS may be considered as adjunct therapies but won't replace the medical necessity for Photrexa in progressive cases.

Prior Authorization Requirements

Documentation Required for Approval:

Requirement Specific Threshold Notes
Progressive Keratoconus Kmax increase ≥1.0 D or pachymetry thinning ≥10 microns Within 12-24 months
Corneal Thickness ≥400 microns after epithelial removal Measured at treatment time
Age Range 14-65 years old May vary by specific plan
Corneal Clarity Clear central cornea, no scarring Documented via slit lamp
Diagnosis Code ICD-10 H18.62x (unstable keratoconus) Required for billing

Clinical Evidence Needed:

  • Serial corneal topography showing progression
  • Pachymetry measurements over time
  • Visual acuity testing (uncorrected and best corrected)
  • Documentation of failed conservative treatments
  • Clear photos of corneal condition

Step-by-Step: Fastest Path to Approval

1. Gather Progressive Evidence (Patient + Doctor)

Timeline: 1-2 weeks

  • Collect serial corneal topography from past 12-24 months
  • Document visual acuity changes
  • Submit via: Humana provider portal

2. Submit Prior Authorization (Doctor's Office)

Timeline: Same day

  • Use CPT code 0402T (corneal cross-linking)
  • Use HCPCS J2787 (2 units per eye for riboflavin)
  • Include ICD-10 H18.62x diagnosis
  • Submit via: Humana provider portal or fax

3. Await Initial Decision

Timeline: Up to 30 days for standard PA

  • Humana must respond within Medicare timelines
  • Expedited review available for urgent cases (72 hours)

4. Schedule Procedure (If Approved)

Timeline: 2-4 weeks

  • Confirm in-network ophthalmologist
  • Verify specialty pharmacy coordination
  • Coordinate via: Provider's office

5. File Appeal (If Denied)

Timeline: Within 65 days of denial

  • Submit redetermination request
  • Include additional clinical evidence
  • Submit via: Humana member portal or mail

Specialty Pharmacy Network

Humana works with major specialty pharmacies including CVS Specialty and Accredo for Photrexa dispensing:

Enrollment Process:

  1. Prior authorization approval required first from Humana
  2. Provider submits prescription to designated specialty pharmacy
  3. Patient enrollment form completed (includes demographics, insurance verification)
  4. Product shipped to treatment facility as single-use 3mL syringes

Key Details:

  • NDC: 25357-0025-03 (11-digit format required)
  • Dosage: 1.46-1.56 mg/mL riboflavin 5'-phosphate
  • Administration: Only with KXL® UV cross-linking system
  • Storage: Specialty pharmacy handles temperature-controlled shipping
Tip: Your eye doctor's office typically coordinates the specialty pharmacy enrollment after Humana approval is confirmed.

Cost-Share Dynamics

Typical Out-of-Pocket Costs (educational information only):

  • Procedure costs: $2,500-$4,000 per eye total (drug + device + facility)
  • Your portion depends on:
    • Annual deductible status
    • Coinsurance percentage (typically 10-20% for Medicare Advantage)
    • Out-of-pocket maximum
    • In-network vs. out-of-network provider

Cost-Saving Options:

  • Manufacturer patient assistance programs (verify eligibility at Glaukos.com)
  • Medicare Extra Help for prescription drug costs
  • State pharmaceutical assistance programs
Important: Contact Humana member services at the number on your ID card for specific cost estimates based on your plan and deductible status.

Appeals Playbook for California

California residents have strong appeal rights with multiple levels of review:

Internal Appeals (Humana)

Timeline: 65 days to file, 7 days for decision

  • File via: Humana member portal, mail, or phone
  • Required: Original denial letter, additional clinical evidence
  • Decision: Binding on Humana if approved

Independent Medical Review (IMR) - California

Timeline: File within 6 months of internal denial

  • Regulated by: California Department of Managed Health Care
  • Process: Independent physicians review medical necessity
  • Timeline: 45 days standard, 7 days expedited
  • Cost: Free to patients
  • Success rate: High for well-documented cases

How to File IMR:

  1. Complete internal appeal with Humana first
  2. File IMR application at healthhelp.ca.gov
  3. Include all medical records and denial letters
  4. DMHC assigns independent review organization
California Advantage: Unlike many states, California's IMR decisions are binding on insurers and have high success rates for medically necessary treatments.

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
"Not medically necessary" Submit progression evidence Serial topography, pachymetry, VA trends
"Experimental/investigational" Emphasize FDA-approved epi-off method FDA approval letter, clinical guidelines
"Missing documentation" Complete clinical record submission All test results, prior treatments, photos
"Age restrictions" Verify plan-specific age limits Birth certificate, plan documents
"Out-of-network provider" Find in-network specialist or request exception Provider directory, medical necessity letter

Counterforce Health specializes in turning these denials into successful appeals by analyzing the specific denial reason and crafting targeted, evidence-backed rebuttals that align with Humana's own coverage policies.

FAQ

How long does Humana prior authorization take in California? Standard PA decisions take up to 30 days. Expedited reviews for urgent cases are completed within 72 hours. Submit through the Humana provider portal for fastest processing.

What if Photrexa is denied as "not medically necessary"? File an internal appeal within 65 days with additional progression documentation. If denied again, California residents can request Independent Medical Review (IMR) through the DMHC.

Does step therapy apply to Photrexa? Humana may require documentation of failed conservative treatments (glasses, contact lenses) before approving cross-linking for progressive keratoconus.

Can I get an expedited appeal in California? Yes, if waiting for standard appeal timelines could jeopardize your vision. Request expedited review when filing your appeal and provide medical documentation supporting urgency.

What counts as "progressive" keratoconus for Humana? At least one of: Kmax increase ≥1.0 D, mean K increase ≥0.7 D, pachymetry thinning ≥10 microns, or visual acuity loss >1 line within 12-24 months.

Are there age limits for Photrexa coverage? Humana typically covers corneal cross-linking for ages 14-65, but specific age ranges may vary by plan. Check your Evidence of Coverage document.

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements for Strong PA Submissions:

✓ Patient demographics and insurance information
✓ Clear diagnosis with ICD-10 H18.62x codes
✓ Progression documentation with specific measurements and dates
✓ Prior treatment failures (glasses, contacts, other interventions)
✓ Contraindications to alternative treatments
✓ Corneal thickness measurements confirming ≥400 microns
✓ Treatment plan specifying epithelium-off technique with iLink® system
✓ Expected outcomes and monitoring plan

Key Clinical Guidelines:

When to Get Help

Contact California Regulators If:

  • Humana doesn't respond to appeals within required timelines
  • You need help understanding your appeal rights
  • You want to file a complaint about coverage denials

California Department of Managed Health Care (DMHC)

  • Phone: (888) 466-2219
  • Website: healthhelp.ca.gov
  • Services: Free IMR applications, complaint investigations, consumer assistance

California Department of Insurance (CDI)

  • Phone: (800) 927-4357
  • For plans not regulated by DMHC

Free Legal Help:

  • Health Consumer Alliance
  • Local legal aid organizations
  • State Health Insurance Assistance Program (SHIP)

From our advocates: "We've seen many Photrexa denials overturned when patients provided clear progression data showing Kmax increases over 6-12 months. The key is submitting complete topography series, not just single measurements. California's IMR process is particularly effective for these cases when internal appeals fail."

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific denial basis, then drafts point-by-point rebuttals using the right clinical evidence and regulatory citations. For complex cases like Photrexa appeals, we help ensure all required documentation meets Humana's specific criteria while tracking deadlines and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with Humana and consult with your healthcare provider about treatment decisions. For personalized assistance with California insurance appeals, contact the DMHC Help Center at (888) 466-2219.

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