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

How to Get Prolastin-C Covered by Humana Medicare in Washington: Complete Guide with Forms and Appeal Scripts

Answer Box: Quick Path to Prolastin-C Coverage

Getting Prolastin-C covered by Humana Medicare in Washington requires prior authorization and may involve step therapy. Here's your fastest path:

  1. Confirm eligibility: Pi*ZZ genotype, FEV1 documentation, and emphysema diagnosis
  2. Submit complete PA: Include AAT levels <11 µM, pulmonary function tests, and medical necessity letter
  3. If denied: Use Washington's automatic external review through an Independent Review Organization (IRO)

First step today: Call Humana at the number on your insurance card to request prior authorization forms for Prolastin-C (HCPCS code J0256). Most approvals take 7-15 business days with complete documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all AAT therapies Humana provider portal Humana 2025 PA List
Step Therapy May need to try preferred brand first Part B Step Therapy list Humana Step Therapy Requirements
Diagnosis Code ICD-10: E88.01 (AAT deficiency) Medical records FDA Prolastin-C Label
Age Requirement 18+ years Clinical documentation Humana Coverage Policies
Genotype PiZZ preferred; PiSZ case-by-case Genetic testing results Clinical studies (verify with source linked below)
Appeals Deadline 65 days from denial notice EOB/denial letter Medicare Appeals Process

Step 1: Confirm Your Eligibility

Before starting the prior authorization process, ensure you meet Humana's medical necessity criteria for Prolastin-C:

Required Diagnosis

  • Alpha-1 antitrypsin deficiency with severe genotype (typically Pi*ZZ)
  • Emphysema documented by CT scan or chest X-ray
  • Age 18 or older

Laboratory Requirements

  • Serum AAT level less than 11 µM (or <57 mg/dL)
  • Genetic testing confirming severe deficiency genotype
  • Pulmonary function tests showing airflow obstruction (FEV1/FVC <70%)
Note: Pi*SZ patients may face additional scrutiny and should prepare strong clinical documentation of symptomatic disease.

Clinical Documentation Needed

Your doctor must document:

  • Diagnosis of emphysema with alpha-1 antitrypsin deficiency
  • Current symptoms affecting quality of life
  • Failure or contraindication to standard COPD therapies
  • Non-smoker status or smoking cessation

Step 2: Gather Required Documentation

For Patients:

  • Insurance card and member ID
  • Recent lab results (AAT level, genetic testing)
  • Pulmonary function test results (within 12 months)
  • CT scan or chest imaging reports
  • List of previous COPD medications tried

For Clinicians:

  • Complete medical history and physical exam
  • ICD-10 diagnosis code E88.01
  • HCPCS code J0256 for billing
  • NDC number for specific Prolastin-C product
  • Medical necessity letter (see template below)

Clinician Corner: Medical Necessity Letter Checklist

Your letter should include:

  1. Patient demographics and insurance information
  2. Diagnosis with ICD-10 code E88.01
  3. Clinical presentation and symptoms
  4. Laboratory confirmation: AAT level <11 µM and genotype
  5. Imaging findings consistent with emphysema
  6. Prior therapies attempted and outcomes
  7. Contraindications to alternative treatments
  8. Treatment plan including dosing (typically 60 mg/kg weekly)
  9. Expected outcomes and monitoring plan
  10. References to FDA labeling and clinical guidelines

Step 3: Submit Your Prior Authorization

Submission Methods

  • Online: Humana provider portal (confirm current link)
  • Fax: Check your specific plan's PA fax number
  • Phone: 1-800-HUMANA (verify with source linked below)

Timeline Expectations

  • Standard review: 14 business days
  • Expedited review: 72 hours (for urgent medical situations)
  • Incomplete submissions: May take 30+ days with requests for additional information
Tip: Submit complete documentation upfront to avoid delays. Missing items are the #1 cause of approval delays.

If You're Denied: Washington Appeals Process

Washington state offers robust patient protections through its Independent Review Organization (IRO) process. Here's your roadmap:

Level 1: Internal Appeal (Required First Step)

  • Timeline: Submit within 65 days of denial
  • Method: Written request to Humana
  • Decision: Within 30 days (7 days for expedited)

Level 2: External Review (Automatic in Washington)

As of 2025, Washington automatically forwards upheld medical necessity denials to an IRO unless you opt out.

  • Timeline: 15 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Reviewer: Specialist in alpha-1 antitrypsin deficiency treatment
  • Decision: Binding on Humana

When to Request Expedited Review

  • Rapid decline in lung function
  • Frequent exacerbations requiring hospitalization
  • Doctor certifies delay could seriously jeopardize health

For assistance with appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient genotype Provide genetic testing PiZZ confirmation or strong PiSZ clinical case
Inadequate lung disease Submit imaging and PFTs CT showing emphysema, FEV1 <65% predicted
Step therapy not met Document contraindications Medical reasons why preferred agent unsuitable
Not medically necessary Strengthen clinical case Exacerbation history, quality of life impact
Missing prior therapies Document treatment history Records of bronchodilators, inhaled steroids tried

Patient Scripts for Phone Calls

Calling Humana for Prior Authorization Status

"Hi, I'm calling to check on the status of a prior authorization request for Prolastin-C. My member ID is [ID number]. The request was submitted on [date] by Dr. [name]. Can you tell me if additional information is needed?"

Requesting Expedited Review

"I need to request an expedited review for my Prolastin-C prior authorization. My doctor has indicated that delays could seriously impact my health due to worsening emphysema. What forms do I need to complete?"

Filing an Appeal

"I received a denial for Prolastin-C coverage and want to file an internal appeal. Can you send me the appeal forms and tell me the deadline for submission? My claim number is [number]."

Cost Assistance Programs

If coverage is denied or you face high out-of-pocket costs:

Manufacturer Support

  • Grifols Patient Assistance Program: Income-based free drug program
  • Copay assistance: May reduce patient costs to $10-50 per infusion
  • Contact: Visit Grifols website or call patient services (verify current number)

Foundation Grants

  • Alpha-1 Foundation: Emergency financial assistance
  • HealthWell Foundation: Copay assistance for rare diseases
  • Patient Advocate Foundation: Appeals assistance and financial aid

State Resources

  • Washington Apple Health: Medicaid expansion may cover AAT therapy
  • Pharmaceutical Assistance Programs: Income-based state programs

FAQ: Prolastin-C Coverage Questions

Q: How long does Humana prior authorization take in Washington? A: Standard reviews take up to 14 business days. Expedited reviews for urgent situations are completed within 72 hours.

Q: What if Prolastin-C is non-formulary on my plan? A: You can request a formulary exception by demonstrating medical necessity and submitting supporting clinical documentation.

Q: Can I appeal if I've been stable on a different AAT therapy? A: Yes, if you have documented medical reasons why Prolastin-C is specifically needed over alternatives, such as infusion site reactions or scheduling conflicts.

Q: Does step therapy apply if I'm switching from another state? A: Step therapy requirements may still apply. Provide documentation of your treatment history and any contraindications to preferred agents.

Q: What's the success rate for AAT therapy appeals in Washington? A: Washington's IRO process has strong patient protections. Success rates vary but are generally favorable when clinical criteria are met and properly documented.

Q: Can I get home infusion coverage? A: Coverage depends on your specific plan benefits. Some Humana plans cover home infusion while others require infusion center administration.

From Our Advocates

We've seen many AAT deficiency patients successfully overturn initial denials by submitting comprehensive genetic testing results alongside detailed pulmonary function documentation. The key is often providing a complete clinical picture that demonstrates both the severity of deficiency and the impact on lung function. Patients who include exacerbation history and quality of life measures tend to have stronger cases during the appeals process.

At Counterforce Health, we help patients navigate complex prior authorization and appeals processes for specialty medications like Prolastin-C. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that align with payer-specific requirements, turning insurance obstacles into successful coverage outcomes.

Whether you're facing a denial or want to strengthen your initial prior authorization, having the right documentation and understanding payer-specific workflows can make the difference between approval and months of delays. For Humana Medicare patients in Washington, the combination of thorough clinical documentation and the state's strong external review protections provides multiple pathways to coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals in Washington state, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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