By Counterforce Health Team in Prolastin-C (alpha1-proteinase inhibitor) —

How to Get Prolastin-C Covered by Humana in Georgia: Complete Forms, Appeals Guide, and Contact Directory

Answer Box: Getting Prolastin-C Covered by Humana in Georgia

Prolastin-C (alpha1-proteinase inhibitor) requires prior authorization from Humana for alpha-1 antitrypsin deficiency with emphysema. Key requirements include Pi*ZZ genotype, AAT levels <11 µM, and FEV₁ 30-65% predicted. Submit via Humana provider portal or fax to 1-877-486-2621 with clinical documentation. If denied, appeal within 65 days internally, then request Georgia DOI external review within 60 days (free process). Contact CenterWell Specialty Pharmacy at 1-800-486-2668 for case management support.

First step today: Verify your Humana plan coverage and gather genotype results, AAT levels, and pulmonary function tests.

Table of Contents

  1. Verify Your Humana Plan and Policy
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Process
  4. Fax and Mail Submission Details
  5. CenterWell Specialty Pharmacy Setup
  6. Support Phone Lines and Contacts
  7. Georgia External Review and Consumer Protection
  8. Common Denial Reasons and Solutions
  9. Appeals Timeline and Process

Verify Your Humana Plan and Policy

Before starting your Prolastin-C prior authorization, confirm your specific Humana coverage type. Different plan types have varying requirements and submission processes.

Coverage Types:

  • Medicare Advantage (Part C): Most common for alpha-1 patients; includes PA requirements
  • Medicare Part D: Prescription drug coverage with specialty tier placement
  • Commercial/Employer Plans: May have different formulary placement
  • Medicaid: State-specific requirements apply
Tip: Check your member ID card for plan type indicators or call the member services number on your card to confirm coverage details.

Key Information to Gather:

  • Member ID and group number
  • Plan effective dates and deductible status
  • Current formulary tier for Prolastin-C
  • In-network prescriber verification

Prior Authorization Forms and Requirements

Clinical Requirements for Approval

Humana's 2024 Medicare coverage requires specific clinical documentation for Prolastin-C approval:

Requirement Details Documentation Needed
Genotype PiZZ, PiZ(null), or Pi*(null,null) Lab report with genetic testing results
AAT Levels <11 µM (80 mg/dL) within 12 months Serum concentration lab report
Lung Function FEV₁ 30-65% predicted (within 6 months) Pulmonary function test results
Imaging Emphysema confirmation CT scan or chest X-ray showing emphysema
Age/Status 18+ years, no IgA deficiency Medical history documentation

Medical Necessity Letter Checklist

Your prescriber's letter must include:

  1. Patient identification with diagnosis (ICD-10: E88.01)
  2. Disease severity documentation (AAT levels, FEV₁ results, imaging)
  3. Prior treatment history including failures or intolerances
  4. Specific rationale for Prolastin-C over alternatives
  5. Dosing plan (60 mg/kg weekly based on weight/BSA)
  6. Monitoring approach for ongoing therapy assessment

Submission Portals and Upload Process

Provider Submission Methods

Primary Portal: Humana Provider Portal

  • Access prior authorization forms for professionally administered drugs
  • Upload supporting clinical documentation
  • Track submission status and receive notifications

Alternative Submission:

  • Fax: 1-877-486-2621 (preferred for PA requests)
  • Phone: 1-888-447-3430 (professionally administered drugs)

Member Self-Service Options

MyHumana Portal: Members can:

  • Check prior authorization status
  • Submit Part D coverage determination requests
  • Access appeal forms and track progress
  • Contact member services via secure messaging

Phone Support: 800-555-2546 (Monday-Friday, 8am-8pm local time)

Fax and Mail Submission Details

Fax Submission Best Practices

Primary Fax: 1-877-486-2621 Cover Sheet Must Include:

  • Member ID and group number
  • Prescriber NPI and DEA numbers
  • Exact drug name: "Prolastin-C (alpha1-proteinase inhibitor)"
  • Dosing: "60 mg/kg weekly"
  • All page count and attachment list
Important: Request fax confirmation receipt and keep for your records. Incomplete submissions add 14 days to processing time.

Required Documentation Checklist

  • Completed PA request form
  • Member ID card copy
  • Prescriber's medical necessity letter
  • Genotype testing results
  • AAT level lab report (within 12 months)
  • Pulmonary function tests (within 6 months)
  • CT scan or chest imaging showing emphysema
  • Prior therapy records and failure documentation

CenterWell Specialty Pharmacy Setup

Getting Started with CenterWell

Contact Information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Hours: Monday-Friday 8am-11pm ET, Saturday 8am-6:30pm ET
  • Emergency: 855-746-0637 (24/7)
  • Fax for new Rx: 1-877-405-7940

Account Setup Process

  1. Register using your existing MyHumana credentials or create new account
  2. Provide member ID card and identifying information
  3. Transfer existing prescriptions or submit new prescription
  4. Schedule delivery and infusion coordination
  5. Access clinical support programs and adherence monitoring

Services Available:

  • Home infusion coordination
  • Financial assistance programs
  • Clinical pharmacist consultations
  • Adherence monitoring and refill reminders
  • Insurance coverage support

Support Phone Lines and Contacts

Member Services

Primary: 800-457-4708 (TTY: 711)

  • Hours: Monday-Friday 8am-8pm local time
  • Services: PA status checks, coverage questions, general inquiries

Expedited Decisions: 866-737-5113

  • Use for urgent prior authorization requests
  • Available for time-sensitive medical situations

Specialty Drug Support

CenterWell Specialty: 1-800-486-2668

  • Case management for complex therapies
  • Prior authorization assistance
  • Clinical program enrollment
  • Financial counseling

Provider Lines

Pharmacy PA: 1-800-555-2546

  • Monday-Friday 8am-8pm local time
  • For providers submitting PA requests

Professionally Administered Drugs: 1-866-461-7273

  • Monday-Friday 8am-6pm ET
  • Status checks for buy-and-bill therapies

Georgia External Review and Consumer Protection

When Internal Appeals Fail

If Humana denies your internal appeal, Georgia law provides external review through the Department of Insurance. This process is free and binding on Humana.

Timeline: Submit within 60 days of Humana's final internal denial notice.

Georgia DOI External Review Process

Contact: Georgia Department of Insurance Consumer Services

Required Documents:

  • Completed external review application (download from DOI website)
  • Copy of Humana's final internal denial letter
  • All supporting medical records and documentation
  • Provider's statement of medical necessity

Decision Timeline:

  • Standard Review: 30 business days
  • Expedited Review: 72 hours (for urgent medical situations)

Additional Georgia Consumer Resources

Georgians for a Healthy Future

  • Provides consumer assistance with appeals
  • Publishes guides on insurance appeals process
  • Can provide one-on-one help or legal aid referrals
From our advocates: "We've seen many Georgia patients successfully overturn Prolastin-C denials through external review, particularly when genetic testing clearly shows Pi*ZZ genotype and pulmonary function tests document the required severity. The key is submitting complete documentation packages that directly address the specific denial reasons."

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient genotype documentation Submit complete genetic testing Lab report showing PiZZ, PiZ(null), or Pi*(null,null)
AAT levels not severe enough Provide recent lab results Serum AAT <11 µM within 12 months
Step therapy not completed Document prior therapy failures Records showing Aralast, Zemaira trials and outcomes
Non-formulary status Request formulary exception Medical necessity letter explaining why alternatives inadequate
Quantity/frequency limits Justify dosing based on weight BSA calculation and FDA labeling reference
Site of care restrictions Provide infusion plan details Home health or infusion center coordination

Appeals Timeline and Process

Internal Appeal with Humana (Required First Step)

Timeline: 65 days from denial notice Submit to:

  • Mail: Humana Grievance and Appeal Department, P.O. Box 14546, Lexington, KY 40512-4546
  • Online: Availity Essentials portal (Claims & Payments > Appeals)

Decision Timeline:

  • Pre-service: 30 days standard, 72 hours expedited
  • Post-service: 60 days

Georgia External Review (After Internal Denial)

Timeline: 60 days from Humana's final internal denial Process:

  1. Call Georgia DOI Consumer Services: 1-800-656-2298
  2. Request external review application form
  3. Gather all documentation from internal appeal
  4. Submit complete package to DOI
  5. Independent medical reviewers evaluate case
  6. Receive binding decision (30 days standard, 72 hours expedited)

Cost: Free to consumers

Expedited Reviews

Available when delay would:

  • Seriously jeopardize your health
  • Compromise your ability to regain maximum function
  • Subject you to severe pain that cannot be adequately managed

Frequently Asked Questions

How long does Humana prior authorization take for Prolastin-C in Georgia? Standard processing is 7 days for Part D, up to 30 days for Part C. Expedited decisions available in 72 hours when health is jeopardized.

What if Prolastin-C is non-formulary on my Humana plan? Request a formulary exception with your prescriber's medical necessity letter explaining why formulary alternatives are inadequate for your condition.

Can I start treatment while waiting for approval? Humana may provide temporary supplies during appeals process. Contact CenterWell Specialty Pharmacy to discuss options and manufacturer assistance programs.

Does step therapy apply if I've tried other AAT therapies outside Georgia? Yes, document all prior alpha-1 proteinase inhibitor trials regardless of location. Include therapy names, duration, outcomes, and reasons for discontinuation.

What happens if I miss the appeal deadline? Contact Georgia DOI Consumer Services immediately at 1-800-656-2298. In some cases, good cause exceptions may apply for late submissions.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to create targeted, evidence-backed responses. Our platform helps patients and clinicians navigate complex prior authorization requirements like those for Prolastin-C, ensuring that appeals address specific payer criteria with appropriate clinical evidence and regulatory citations. If you're facing challenges with your Humana coverage determination, Counterforce Health can help streamline the appeals process and improve your chances of approval.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current information with Humana and consult your healthcare provider for medical decisions. For specific legal guidance regarding insurance appeals in Georgia, consider consulting with a qualified attorney or contacting Georgia Legal Services.

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