By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (Selpercatinib) Covered by Humana in Georgia: Complete Prior Authorization Guide

Quick Answer: Getting Retevmo Covered by Humana in Georgia

Retevmo (selpercatinib) requires prior authorization from Humana for RET fusion-positive cancers. Your fastest path to approval: (1) Confirm RET alteration via FDA-approved testing, (2) Submit PA request through Humana's provider portal with oncologist documentation, and (3) Allow 7-14 days for decision. If denied, you have 65 days to appeal and can request external review through Georgia's Department of Insurance within 60 days of final denial.

Start today: Gather your RET fusion test results and contact your oncologist to begin the medical necessity letter.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Management
  6. If You Need More Information
  7. If Your Request Is Denied
  8. Appeals Process in Georgia
  9. Renewal and Re-authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps patients with RET fusion-positive cancers and their healthcare teams navigate Humana's prior authorization process for Retevmo (selpercatinib) in Georgia. Whether you're dealing with non-small cell lung cancer (NSCLC), medullary thyroid cancer, or other RET fusion-positive tumors, we'll walk you through each step to maximize your chances of approval.

Retevmo costs approximately $23,000-$26,000 per month without insurance coverage, making prior authorization essential for most patients. The good news? Humana's denial rate is relatively low at 5.8% for Medicare Advantage plans, and appeals frequently succeed when properly documented.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for patients facing coverage challenges with specialty medications like Retevmo. Their platform helps identify denial reasons and drafts point-by-point rebuttals aligned to each plan's specific requirements.

Before You Start: Verify Your Coverage

Check Your Plan Type

First, confirm whether you have Humana Medicare Advantage, Medicare Part D, or a commercial Humana plan. The prior authorization process varies slightly:

  • Medicare Advantage/Part D: 7-day standard response (14 days pre-2026), 72-hour expedited option
  • Commercial plans: Follow state insurance regulations with 30-day standard timelines

Verify Network Status

Ensure your oncologist and preferred pharmacy are in-network. Out-of-network providers may require additional documentation or face automatic denials.

Formulary Check

Retevmo appears on Humana's prior authorization list but specific tier placement varies by plan. Check your formulary through:

Gather Required Documentation

Essential Clinical Documentation

Requirement Details Where to Obtain
RET Fusion/Mutation Testing FDA-approved companion diagnostic (Oncomine Dx, FoundationOne CDx, or TruSight Oncology) Oncology clinic lab results
Diagnosis with ICD-10 Specific cancer type (e.g., C78.00 for metastatic NSCLC) Medical records
Prior Treatment History Previous therapies, outcomes, progression reasons Oncologist notes
Contraindications Why alternatives aren't suitable Clinical documentation
Baseline Safety Assessment ECG for QT monitoring, liver function tests Recent lab/cardiac results

Humana-Specific Forms

Download the Request for Medicare Prescription Drug Coverage Determination form or use the provider-specific PA form. New enrollees with existing Retevmo treatment get a 90-day PA waiver with treatment records.

Submit Your Prior Authorization Request

Submission Methods (Ranked by Speed)

  1. Online Portal (Fastest): Humana Provider Portal
  2. Evolent Portal: Call 844-926-4528 (option 5) for specialty drug PAs
  3. Fax: 877-486-2621 using the coverage determination form
  4. Phone: 1-866-461-7273 (Mon-Fri, 8am-6pm ET)

Medical Necessity Letter Checklist

Your oncologist's letter should include:

  • Clinical rationale: Why Retevmo is medically necessary for your specific RET alteration
  • FDA indication alignment: Confirm your diagnosis matches approved uses
  • Prior therapy failures: Document progression or intolerance to previous treatments
  • Safety monitoring plan: Address QT prolongation risk and drug interactions
  • Supporting literature: Reference NCCN guidelines and FDA labeling
Tip: Include the specific RET fusion type (e.g., KIF5B-RET) and testing method to demonstrate FDA-approved companion diagnostic use.

Follow-Up and Timeline Management

Standard Timelines

  • Humana Medicare Advantage: 7 days (starting 2026), 14 days (through 2025)
  • Expedited requests: 72 hours for urgent medical needs
  • Commercial plans: Up to 30 days

Follow-Up Schedule

Day 3-5: Call to confirm receipt and completeness Day 7-10: Check status and ask about any missing information Day 12-14: If no decision, escalate to supervisor

Status Check Script

"Hi, I'm calling to check the status of a prior authorization request for Retevmo submitted on [date]. The reference number is [if available]. Can you tell me if any additional information is needed and when I can expect a decision?"

If You Need More Information

Common requests from Humana include:

  • Additional safety documentation: Baseline ECG, drug interaction review
  • Treatment history clarification: More detailed prior therapy records
  • Peer-to-peer review: Direct physician-to-physician discussion

For peer-to-peer requests, your oncologist can call the number provided in the PA response. These conversations often resolve approval quickly when clinical rationale is clear.

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Missing RET testing Submit FDA-approved companion diagnostic results
Wrong tumor type Clarify diagnosis matches FDA-approved indications
Insufficient prior therapy Document treatment failures or contraindications
Safety concerns Provide cardiac monitoring plan and drug interaction review

First-Level Appeal

You have 65 days from the denial notice to file an internal appeal with Humana. Include:

  • Original PA request and denial letter
  • Additional supporting documentation
  • Updated medical necessity letter addressing denial reasons

Appeals Process in Georgia

Internal Appeal Timeline

  • Filing deadline: 65 days from denial notice
  • Humana decision time: 30 days standard, 72 hours expedited
  • Required documentation: Medical records, physician letter, denial notice

External Review Through Georgia DOI

If Humana upholds the denial, you can request external review through the Georgia Department of Insurance:

  • Filing deadline: 60 days from final denial
  • Process: Independent medical review by specialty physicians
  • Cost: Free to consumers
  • Timeline: 30 business days standard, 72 hours expedited
  • Contact: 1-800-656-2298 or online complaint form
Note: Georgia's external review is binding on insurers and provides a powerful tool for overturning wrongful denials.

When to Escalate

Contact Georgia's Consumer Services Division if:

  • Humana misses decision deadlines
  • You need help filing external review
  • You suspect improper denial practices

Organizations like Counterforce Health can help craft evidence-backed appeals that address specific denial reasons with targeted medical literature and payer policy alignment.

Renewal and Re-authorization

Most Retevmo approvals require renewal every 6-12 months. Calendar your renewal 30-45 days before expiration and include:

  • Updated imaging showing treatment response
  • Continued medical necessity documentation
  • Any new safety monitoring results
  • Confirmation of ongoing RET-positive status

Quick Reference Checklist

Before submitting:

  • RET fusion/mutation test results (FDA-approved method)
  • Diagnosis with ICD-10 code
  • Prior treatment history and failures
  • Baseline safety assessments (ECG, LFTs)
  • Medical necessity letter from oncologist

Submission:

  • Use Humana provider portal or Evolent system
  • Include all required forms and documentation
  • Note reference number for tracking
  • Set follow-up reminders

If denied:

  • Review denial reason carefully
  • File appeal within 65 days
  • Consider peer-to-peer review
  • Prepare for Georgia external review if needed

Frequently Asked Questions

How long does Humana prior authorization take for Retevmo? Standard requests: 7-14 days. Expedited requests for urgent medical needs: 72 hours.

What if Retevmo isn't on my formulary? Request a formulary exception with medical necessity documentation showing why covered alternatives aren't suitable.

Can I get an expedited appeal in Georgia? Yes, both Humana internal appeals and Georgia external review offer expedited options for urgent medical situations.

Does step therapy apply to Retevmo? Retevmo doesn't appear on Humana's Part B step therapy list, but prior treatment documentation is still required.

What if I'm new to Humana and already taking Retevmo? New Medicare enrollees get a 90-day PA waiver with treatment records while Humana reviews your case.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact Humana directly for plan-specific requirements. For additional support with insurance appeals, consider consulting with patient advocacy organizations or legal assistance programs in Georgia.

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