By Counterforce Health Team in Retevmo (selpercatinib) —

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

Answer Box: Getting Retevmo (Selpercatinib) Covered by Humana in Illinois

Retevmo requires prior authorization from Humana and is typically non-formulary, requiring a formulary exception request. The fastest path to approval: 1) Confirm RET alteration with FDA-approved genetic testing, 2) Have your oncologist submit a comprehensive prior authorization through Humana's provider portal with clinical documentation, and 3) Request expedited review if medically urgent (72-hour decision vs. 7 days standard). Start today by asking your care team to gather RET test results, prior therapy records, and clinical notes. If denied, you have 65 days to appeal in Illinois with strong external review rights.

Table of Contents

Plan Types & Coverage Implications

Humana offers several plan types in Illinois, each with different implications for Retevmo coverage:

Medicare Advantage Plans: Most common Humana coverage in Illinois. Retevmo falls under Part D (prescription drug) coverage since it's an oral medication. These plans have standardized Medicare appeal rights with 65-day filing windows.

Commercial Plans: Employer-sponsored coverage with varying formularies. May have different prior authorization criteria than Medicare plans, but similar specialty pharmacy requirements apply.

Medicaid Plans: Humana's Illinois Medicaid managed care plans follow state Medicaid guidelines, which may be more restrictive for high-cost specialty drugs.

Note: Network restrictions don't typically apply to specialty pharmacy drugs like Retevmo, as they're dispensed through designated specialty pharmacies regardless of your plan's network.

Formulary Status & Tier Placement

Current Status: Retevmo is not explicitly listed on most 2024 Humana Medicare Advantage formularies, indicating it's treated as a non-formulary specialty drug. When covered, it's typically placed on the highest cost-sharing tier (Tier 5 specialty).

Alternative Agents: Humana may prefer step therapy with other RET inhibitors like Gavreto (pralsetinib) if listed on formulary. For medullary thyroid cancer, multikinase inhibitors like cabozantinib or vandetanib may be preferred first-line options.

Formulary Exception Process: Since Retevmo is often non-formulary, your prescriber must request a formulary exception alongside the prior authorization, demonstrating that formulary alternatives are medically inappropriate.

Prior Authorization Requirements

Required Clinical Documentation

Your oncologist must submit comprehensive documentation including:

  • RET Alteration Confirmation: FDA-approved genetic test results (such as Oncomine Dx Target Test) showing RET fusion or mutation
  • Appropriate Diagnosis Codes: ICD-10 codes for qualifying cancers (RET fusion-positive NSCLC, medullary thyroid cancer, or RET fusion-positive thyroid cancer)
  • Prior Treatment History: Documentation of previous therapies attempted, including reasons for discontinuation or failure
  • Clinical Assessment: Prescriber explanation of medical necessity and why formulary alternatives would be inappropriate or cause adverse effects

Medical Necessity Criteria

Based on Humana's specialty drug policies, approval typically requires:

  • Confirmed RET alteration via FDA-approved testing
  • Appropriate cancer diagnosis matching FDA-approved indications
  • Documentation that patient meets clinical criteria for targeted therapy
  • Assessment of contraindications and drug interactions

Specialty Pharmacy Requirements

Mandatory Specialty Pharmacy Dispensing: Retevmo must be dispensed through CenterWell Specialty Pharmacy, Humana's preferred specialty pharmacy partner. Standard retail pharmacies cannot dispense this medication under Humana coverage.

Patient Setup Process:

  1. Prior authorization approval required before specialty pharmacy can process prescription
  2. CenterWell contacts patient to set up delivery and provide medication counseling
  3. Ongoing clinical monitoring and refill coordination handled by specialty pharmacy team

Available Strengths: 40 mg, 80 mg, 120 mg, and 160 mg capsules, with standard dosing of 160 mg twice daily.

Cost-Share Dynamics

Specialty Tier Costs: When covered, expect specialty tier cost-sharing, which can range from $100-$290 per 30-day supply for Medicare Advantage plans, depending on your specific plan design.

Deductible Application: Specialty drugs typically count toward your plan's deductible. For Medicare Part D plans, this means you may pay full cost until reaching the deductible threshold.

Coverage Gap Considerations: For Medicare beneficiaries, Retevmo costs will count toward the catastrophic coverage threshold, but expect significant out-of-pocket costs in the coverage gap phase.

Submission Process

How to Submit Prior Authorization

Fastest Method: Humana provider portal (72-hour standard decision timeline)

Alternative Methods:

  • Fax: 877-486-2621
  • Phone: 800-555-CLIN (2546), Monday–Friday, 8 a.m.–8 p.m.

Required Form: "Request for Medicare Prescription Drug Coverage Determination" available through Humana's member portal.

Decision Timelines

  • Standard Review: 72 hours from complete submission
  • Expedited Review: 24 hours when delay could seriously harm health

Common Approval Patterns

Strong submissions typically include:

  • Complete genetic testing report with clear RET alteration documentation
  • Detailed treatment history with specific dates and outcomes
  • Clinical notes explaining why Retevmo is the most appropriate therapy
  • Assessment of monitoring plan for known side effects (liver function, QT interval)

Clinician Corner: Medical necessity letters should address FDA-approved indications, cite NCCN guidelines for biomarker-driven therapy selection, and document any contraindications to alternative agents.

Appeals Playbook for Illinois

Internal Appeals Process

Level 1 - Redetermination:

Level 2 - Independent Review Entity (IRE):

  • Deadline: 60 days from redetermination denial
  • Decision Timeline: 7 days standard, 72 hours expedited
  • Review: External physician reviewer with oncology expertise

Illinois External Review Rights

If Medicare appeals are exhausted, Illinois residents have additional protections under the Health Carrier External Review Act:

  • Deadline: 30 days from final adverse determination (shorter than many states)
  • Process: Independent Review Organization (IRO) with board-certified physician
  • Timeline: Decision within 5 business days of receiving medical records
  • Cost: No fee for consumers; insurers pay review costs

Illinois Department of Insurance: 877-527-9431 for consumer assistance with appeals and external reviews.

Important: Illinois has a stricter 30-day deadline for external review compared to the 4-month window in many states. Act promptly after appeal denials.

When to Escalate

Contact Illinois regulators if you experience:

  • Delayed decisions beyond regulatory timeframes
  • Requests for non-standard documentation
  • Denial of expedited review for urgent cases

Illinois Department of Insurance Office of Consumer Health Insurance: 877-527-9431 Illinois Attorney General Health Care Helpline: 1-877-305-5145

FAQ

How long does Humana prior authorization take in Illinois? Standard decisions within 72 hours; expedited decisions within 24 hours when medically urgent. Submit through provider portal for fastest processing.

What if Retevmo is non-formulary on my plan? Your prescriber can request a formulary exception alongside the prior authorization, demonstrating medical necessity and inappropriateness of formulary alternatives.

Can I request expedited review? Yes, when delay would seriously jeopardize your health. Your prescriber must document the urgency and submit supporting clinical evidence.

What genetic testing is required? FDA-approved companion diagnostics such as the Oncomine Dx Target Test are required to confirm RET alteration status.

Does step therapy apply if I've tried other treatments outside Illinois? Prior therapy documentation from any location is typically accepted. Provide complete treatment records including dates, outcomes, and reasons for discontinuation.

How much will Retevmo cost with Humana coverage? Specialty tier cost-sharing typically ranges from $100-$290 per 30-day supply for Medicare plans, though exact costs depend on your specific plan design and deductible status.

What happens if my appeal is denied? Illinois residents can request external review within 30 days through the state's Independent Review Organization process, with binding decisions made by independent physicians.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific submissions. The platform identifies denial reasons and crafts targeted rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines while ensuring all procedural requirements are met.

For complex Retevmo denials, platforms like Counterforce Health can help craft comprehensive appeals that address Humana's specific coverage criteria while incorporating Illinois regulatory requirements and deadlines.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For assistance with Illinois insurance regulations, contact the Illinois Department of Insurance at 877-527-9431.

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