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

How to Get Prolastin-C Covered by Humana in Texas: Complete Requirements Checklist and Appeals Guide

Quick Answer: Getting Prolastin-C Covered by Humana in Texas

Prolastin-C requires prior authorization from Humana with strict clinical documentation. You'll need confirmed Pi*ZZ genotype, AAT levels below 11 µM, FEV₁ between 30-65% predicted, and emphysema documentation. First step today: Have your doctor submit a prior authorization request to Humana at 1-877-486-2621 with complete clinical records. If denied, Texas law gives you 65 days to appeal internally, plus independent external review through the Texas Department of Insurance. Expected timeline: 7-30 days for initial decision, 72 hours for expedited appeals.

Table of Contents

Who Should Use This Checklist

This guide is designed for patients diagnosed with alpha-1 antitrypsin deficiency and their healthcare providers seeking Humana coverage for Prolastin-C in Texas. You should use this checklist if:

  • Your doctor has prescribed Prolastin-C for confirmed alpha-1 antitrypsin deficiency
  • You have Humana Medicare Advantage or Medicare Part D coverage
  • You're experiencing coverage denials or want to prevent them
  • You need to understand the appeals process in Texas

Expected outcome: Following this checklist significantly improves your chances of approval by ensuring all required documentation is complete before submission.

Member & Plan Basics

Coverage Verification Requirements

Before starting the prior authorization process, confirm these basics:

Note: Humana's Medicare Advantage PA denial rate is approximately 3.5%, among the lowest of major insurers, but proper documentation is critical.

Clinical Criteria Requirements

FDA-Approved Indication

Prolastin-C is approved for chronic augmentation therapy in adults with emphysema due to severe alpha-1 antitrypsin deficiency. Coverage requires meeting all of these criteria:

Required Clinical Documentation

1. Genotype Confirmation

2. Serum AAT Levels

  • AAT concentration below 11 µM (80 mg/dL) within the previous 12 months
  • Laboratory report must be included with PA request

3. Lung Function Requirements

  • FEV₁ between 30-65% of predicted value, OR
  • Documented rapid decline (>100 mL/year) in FEV₁
  • Pulmonary function tests dated within 6 months

4. Imaging Evidence

  • CT scan or chest X-ray confirming emphysema or COPD
  • Radiologist report must be included

5. Age and Safety Requirements

  • Patient must be 18 years or older
  • No significant IgA deficiency with anti-IgA antibodies
  • Liver-only manifestations without lung disease do not qualify

Coding and Billing Requirements

HCPCS Coding for Prolastin-C

Primary Code: J0256 - "Injection, alpha 1-proteinase inhibitor, human, 10 mg"

Billing Units Calculation:

  • Each unit represents 10 mg of Prolastin-C
  • Typical dose: 60 mg/kg weekly
  • Example: 70 kg patient = 420 mg weekly = 42 billing units

ICD-10 Diagnosis Codes:

  • E88.01 - Alpha-1-antitrypsin deficiency
  • J43.9 - Emphysema, unspecified
  • J44.1 - Chronic obstructive pulmonary disease with acute exacerbation

Modifier Requirements

No specific modifiers are mandated for Prolastin-C under Medicare Part B, but standard Medicare modifiers may apply based on service setting.

Documentation Packet Essentials

Provider Note Requirements

Your physician's clinical note must include:

  1. Diagnosis confirmation with ICD-10 codes
  2. Treatment history including prior therapies tried and failed
  3. Clinical rationale for Prolastin-C specifically
  4. Dosing justification based on patient weight and BSA
  5. Treatment goals and monitoring plan

Medical Necessity Letter Components

The letter should contain:

  • Patient identifying information and Humana member ID
  • Prescribed drug name, dosage (60 mg/kg), and frequency (weekly)
  • Detailed medical history relevant to AAT deficiency
  • Explanation of why alternative treatments are not suitable
  • Clinical rationale with supporting literature references
  • Provider signature and NPI number

Required Attachments Checklist

  • Genotype laboratory report (Pi*ZZ confirmation)
  • Serum AAT level results (below 11 µM)
  • Recent pulmonary function tests (FEV₁ documentation)
  • CT scan or chest imaging showing emphysema
  • Clinical notes supporting diagnosis and treatment plan
  • Prior therapy documentation (if applicable)

Submission Process

Humana Prior Authorization Submission

Preferred Method: Fax to 1-877-486-2621 Phone Support: Available Monday-Friday, 8 a.m.-8 p.m. EST

Required Fields That Commonly Cause Rejections:

  • Complete member ID and group number
  • Prescriber NPI and DEA numbers
  • Specific drug name (Prolastin-C, not generic)
  • Exact dosing and frequency
  • All supporting clinical documentation attached
Tip: Always request a confirmation number when submitting by fax and keep records of all submission attempts.

Timeline Expectations

  • Standard review: Up to 30 days for Part C, 7 days for Part D
  • Expedited review: 72 hours if delay could jeopardize health
  • Incomplete submissions: Additional 14 days after missing information is provided

Specialty Pharmacy Coordination

Humana's Preferred Network in Texas

Primary Vendor: Accredo Specialty Pharmacy through PROLASTIN DIRECT® Program

  • Phone: 1-833-PHONEA1 (833-746-6321)
  • Handles all logistics including home infusion coordination
  • Alpha-1 trained registered nurses provide in-home care

Alternative: CenterWell Specialty Pharmacy (Humana-owned)

  • Phone: 1-800-486-2668
  • Verify home infusion eligibility with benefits manager

Transfer Process

  1. Have your physician send prescription directly to Accredo
  2. Accredo coordinates with Humana for PA approval
  3. Patient automatically enrolled in PROLASTIN DIRECT program
  4. Confirm approved site of care (home, work, or infusion center)

After Submission: Tracking and Follow-up

What to Record

  • Submission date and confirmation number
  • All documents sent and method of delivery
  • Follow-up call dates and representatives spoken with
  • Any additional information requests from Humana

Status Check Schedule

  • Day 3: Confirm receipt of submission
  • Day 7: Check processing status for Part D requests
  • Day 14: Follow up on any missing information requests
  • Day 25: Final status check before deadline (Part C)

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

1. Incomplete Genotype Documentation

  • Problem: Submitting phenotype instead of genotype results
  • Solution: Ensure laboratory report specifically states PiZZ, PiZ(null), or Pi*(null,null)

2. Outdated Pulmonary Function Tests

  • Problem: PFTs older than 6 months
  • Solution: Obtain recent spirometry showing FEV₁ 30-65% predicted

3. Missing IgA Deficiency Screening

  • Problem: Not documenting absence of IgA deficiency
  • Solution: Include lab results showing normal IgA levels

4. Inadequate Prior Therapy Documentation

  • Problem: Failing to document step therapy attempts
  • Solution: Provide detailed records of bronchodilators, steroids, and other COPD treatments tried

5. Incorrect Billing Code Usage

  • Problem: Using wrong HCPCS code or miscalculating units
  • Solution: Always use J0256 and calculate units as total mg ÷ 10

Appeals Process for Texas Residents

If your Prolastin-C request is denied, Texas provides strong appeal rights:

Internal Appeals Timeline

  • Deadline: 65 days from denial notice
  • Standard decision: 7 days for Part D, 30 days for Part C
  • Expedited decision: 72 hours if delay threatens health

External Review Rights

Texas law provides independent external review through the Texas Department of Insurance for medical necessity denials:

  • Deadline: 4 months from final internal denial
  • Decision timeline: 20 days standard, 5 days for urgent cases
  • Cost: Paid by Humana, free to patient
  • Binding: Humana must comply with favorable IRO decisions

Getting Help in Texas

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926
From our advocates: "We've seen the strongest Prolastin-C appeals include a peer-reviewed study showing AAT augmentation slows emphysema progression, combined with the patient's specific FEV₁ decline rate. This evidence-based approach, paired with complete genotype documentation, significantly improves approval rates in our experience."

Quick Reference Checklist

Before You Start

  • Confirm active Humana coverage and member ID
  • Verify prescriber is in-network
  • Gather all required clinical documentation

Clinical Requirements

  • Pi*ZZ genotype laboratory report
  • AAT level below 11 µM (within 12 months)
  • FEV₁ 30-65% predicted (within 6 months)
  • CT scan confirming emphysema
  • Age 18+ with no IgA deficiency

Submission Checklist

  • Complete PA form with all required fields
  • Medical necessity letter from prescriber
  • All clinical attachments included
  • Faxed to 1-877-486-2621 with confirmation
  • Specialty pharmacy coordination initiated

After Submission

  • Record confirmation number and submission date
  • Schedule status check calls
  • Prepare appeal documents if needed
  • Coordinate with Accredo for fulfillment

FAQ

Q: How long does Humana prior authorization take for Prolastin-C in Texas? A: Standard review is 7 days for Part D and up to 30 days for Part C. Expedited review is completed within 72 hours if delay could jeopardize your health.

Q: What if Prolastin-C is non-formulary on my Humana plan? A: You can request a formulary exception by demonstrating medical necessity and providing clinical documentation showing why preferred alternatives are not suitable.

Q: Can I request an expedited appeal in Texas? A: Yes, if waiting for standard review could seriously harm your health. Both Humana and Texas external review offer expedited timelines (72 hours and 5 days respectively).

Q: Does step therapy apply if I've tried treatments outside Texas? A: Yes, prior therapy documentation from any state is acceptable. Provide complete records of bronchodilators, corticosteroids, and other COPD treatments attempted.

Q: What happens if Humana denies my appeal? A: Texas residents can request independent external review through the Texas Department of Insurance. This review is binding on Humana and free to patients.

Q: How much does Prolastin-C cost with Humana coverage? A: Costs vary by plan, but annual treatment typically exceeds $80,000. Check your specific copay, coinsurance, and out-of-pocket maximum with Humana member services.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, significantly improving approval rates for complex specialty medications like Prolastin-C.

Getting Prolastin-C approved by Humana requires meticulous attention to clinical documentation and Texas-specific appeal procedures. While the process can seem overwhelming, following this systematic approach—from initial submission through potential appeals—gives you the best chance of securing coverage for this life-changing therapy. Remember that Counterforce Health specializes in transforming complex insurance denials into successful appeals, providing the expertise needed to navigate challenging coverage decisions.

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 representative for personalized guidance. Texas insurance appeal rights and timelines are subject to change; verify current requirements with the Texas Department of Insurance.

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