By Counterforce Health Team in Rapivab (peramivir) —

How to Get Rapivab (Peramivir) Covered by Humana in Washington: Forms, Appeals & Provider Contacts

Answer Box: Getting Rapivab (Peramivir) Covered by Humana in Washington

Rapivab (peramivir) requires prior authorization from Humana Medicare Advantage and most commercial plans. Your fastest path: Have your provider submit a PA request via Humana's portal or fax (877-486-2621) with clinical justification for IV therapy over oral alternatives. If denied, you have 60 days to appeal internally, then request external review through Washington's Independent Review Organization. Start today: Verify your plan's formulary status and gather documentation of symptom onset ≤48 hours and contraindications to oral antivirals.

Table of Contents

  1. Start Here: Verify Your Plan Coverage
  2. Required Forms for Prior Authorization
  3. Submission Portals and Methods
  4. Fax Numbers and Mailing Addresses
  5. Provider Contact Numbers
  6. Appeals Process in Washington
  7. Washington State Insurance Commissioner Resources
  8. Common Denial Reasons and Solutions
  9. When to Update Your Information

Start Here: Verify Your Plan Coverage

Before requesting Rapivab (peramivir), confirm your specific Humana plan requirements. Rapivab is an IV neuraminidase inhibitor for acute, uncomplicated influenza that must be given within 48 hours of symptom onset.

Coverage Requirements at a Glance:

Requirement Details Where to Check
Prior Authorization Required for most plans Humana PA Search Tool
Formulary Status Often non-formulary or high-tier Humana Drug List
Medical Necessity Must document why oral options unsuitable Plan policy documents
Timing Requirement Within 48 hours of flu symptom onset FDA labeling requirements
Site of Care Hospital or infusion center administration Plan coverage policies
Note: Humana's Medicare Advantage PA denial rate is approximately 3.5%—among the lowest of major insurers—but denials often occur due to incomplete documentation or timing issues.

Required Forms for Prior Authorization

Primary Forms

For Medicare Part D Plans:

  • Medicare Prescription Drug Coverage Determination Form (available on Humana provider portal)
  • Prior Authorization Request Form for specialty medications

For Medicare Advantage (Part C):

  • Medical Prior Authorization Form for professionally administered drugs
  • Exception Request Form if Rapivab is non-formulary

For Commercial Plans:

  • Standard Prior Authorization Form
  • Medical Necessity Documentation from prescribing physician

Supporting Documentation Required

Your provider must include:

  • Medical necessity letter explaining why oral antivirals (oseltamivir, zanamivir) or baloxavir are unsuitable
  • Documentation of symptom onset within 48 hours
  • Positive influenza test results (if required by plan)
  • Patient weight and renal function for dosing calculations
  • Prior therapy failures or contraindications to covered alternatives
Clinician Corner: The medical necessity letter should specifically address why IV therapy is required over oral options. Common justifications include: inability to tolerate oral medications due to vomiting, malabsorption issues, or severe illness requiring hospitalization.

Submission Portals and Methods

Electronic Submission (Preferred)

Availity Essentials Portal: Humana's designated provider portal for secure submission and tracking

  • Access: provider.humana.com
  • Features: Real-time status updates, document uploads, eligibility verification
  • Account required: Yes (free provider registration)

CoverMyMeds Integration: Available for pharmacy prior authorizations

  • Streamlined electronic PA submission
  • Automatic form population from EHR systems

CenterWell Specialty Pharmacy

For specialty drug coordination:

  • Phone: 1-800-486-2668
  • Fax: 1-877-405-7940
  • E-prescribing: Preferred method for efficiency

Fax Numbers and Mailing Addresses

Prior Authorization Fax Numbers

Request Type Fax Number Purpose
Pharmacy PA (Part D) 877-486-2621 Standard medication requests
Professionally Administered Drugs 888-447-3430 Office/hospital-administered medications
Commercial Plan PA 800-658-9457 Non-Medicare commercial plans
Expedited Reviews 866-737-5113 Urgent medical situations

Cover Sheet Requirements

When faxing, include:

  • Patient name and Humana ID number
  • Prescriber name and NPI
  • Medication name (Rapivab/peramivir) and NDC code
  • Urgency level (standard or expedited)
  • Complete page count

Provider Contact Numbers

Clinical Review Team

  • Primary: 800-555-CLIN (2546)
  • Hours: Monday–Friday, 8 a.m.–8 p.m. local time
  • Purpose: Specialty drug PA, case management

Medical/Pharmacy Preauthorizations

  • General: 800-457-4708 (TTY: 711)
  • Hours: 7 days/week, 8 a.m.–8 p.m. Eastern
  • Purpose: Standard PA requests, status inquiries

24/7 Clinical Intake

  • Emergency: 800-523-0023
  • Purpose: Urgent clinical issues, case management

Peer-to-Peer Review Requests

  • Provider line: 866-488-5995
  • Purpose: Clinical discussion with medical director
  • When to use: After initial PA denial, before formal appeal

Appeals Process in Washington

Internal Appeals (Required First Step)

Timeline: 60 days from denial letter date to file Response time:

  • Standard: 30 days (Part C), 7 days (Part D)
  • Expedited: 72 hours (Part C), 24 hours (Part D)

Required documents:

  • Original denial letter
  • Provider letter supporting medical necessity
  • Additional clinical documentation
  • Patient authorization (if representative filing)

External Review (Independent Review Organization)

If Humana denies your internal appeal, Washington residents can request external review through an Independent Review Organization (IRO).

Key details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to patient
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Authority: IRO decision is binding on Humana

How to request:

  1. Submit request to Washington Office of Insurance Commissioner or directly to Humana
  2. OIC assigns certified IRO from rotational registry
  3. Humana must send all records to IRO within 3 business days
  4. You have 5 business days to submit additional information

Appeal Letter Template

[Date]
Humana Appeals Department
[Address from denial letter]

RE: Appeal for [Patient Name], ID: [Member ID], Claim: [Number]

I am formally appealing the denial of coverage for Rapivab (peramivir) 
dated [denial date]. The denial reason stated was "[quote exact reason]."

This medication is medically necessary because:
- Patient developed influenza symptoms on [date], confirmed by [test type]
- Oral antivirals are contraindicated due to [specific medical reason]
- IV peramivir is the only appropriate treatment option given [clinical factors]

Enclosed documentation:
- Prescriber medical necessity letter
- Laboratory results confirming influenza
- Medical records supporting contraindications to oral therapy
- [Additional relevant documents]

Please reconsider this denial and approve coverage for this medically 
necessary treatment.

[Signature]
[Contact information]

Washington State Insurance Commissioner Resources

Consumer Assistance

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Services: Appeal guidance, template letters, complaint filing

Appeal Templates and Guides

Washington OIC provides comprehensive appeals guidance including:

  • Step-by-step appeal instructions
  • Template letters for different denial reasons
  • Timeline tracking worksheets
  • Contact information for additional help

External Review Process

The OIC maintains a registry of certified Independent Review Organizations and can assist with:

  • Filing external review requests
  • Understanding your rights under Washington law
  • Escalating issues with insurer compliance
From our advocates: We've seen Washington patients successfully overturn Rapivab denials by clearly documenting the 48-hour symptom onset window and providing specific contraindications to oral alternatives. The key is thorough documentation from the prescriber explaining why IV therapy is the only suitable option.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Symptom onset >48 hours" Provide precise symptom diary Patient/family attestation, medical records
"Oral alternatives not tried" Document contraindications Medical history, allergy records, prior failures
"Not medically necessary" Clinical justification letter Provider assessment, treatment rationale
"Non-formulary drug" File exception request Comparative effectiveness data, medical necessity
"Quantity limits exceeded" Justify dosing requirements Weight-based calculations, renal adjustments

Medical Necessity Criteria

Humana typically approves Rapivab when documentation shows:

  • Confirmed influenza within 48 hours of symptom onset
  • Inability to take or absorb oral medications
  • Clinical severity requiring IV therapy
  • Contraindications to covered alternatives
  • Appropriate dosing based on weight and renal function

When to Update Your Information

Annual Updates (January)

  • Review new formulary lists
  • Check updated PA requirements
  • Verify provider network changes
  • Update contact information

Mid-Year Changes

  • Monitor plan communications for formulary updates
  • Check for new generic alternatives
  • Review coverage determination changes
  • Update emergency contact information

Before Each Prescription

  • Confirm current PA status
  • Verify prescriber is in-network
  • Check for any new step therapy requirements
  • Review copay/coinsurance changes

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes. Our platform analyzes denial letters, identifies specific coverage criteria, and generates targeted appeals with evidence-backed medical necessity documentation. By understanding each payer's unique requirements and workflows, we help turn insurance denials into approvals while saving time for busy healthcare providers. Learn more about our coverage determination services at counterforcehealth.org.

Sources & Further Reading

Important Disclaimer

This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements change frequently. Always verify current information with your insurance plan and healthcare provider. For personalized assistance with appeals or coverage determinations, consult with your healthcare team or contact the Washington State Office of Insurance Commissioner at 1-800-562-6900.

Need help with your Humana coverage determination? Counterforce Health specializes in turning insurance denials into approvals through evidence-based appeals and comprehensive documentation support.

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