By Counterforce Health Team in Retevmo (selpercatinib) —

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

Quick Answer: Getting Retevmo Covered by Humana in New York

Retevmo (selpercatinib) requires prior authorization under Humana Medicare plans and may be non-formulary depending on your specific plan. To get coverage in New York: 1) Have your oncologist submit a prior authorization request with RET mutation testing results and medical necessity documentation, 2) If denied, file an internal appeal within 65 days, then 3) Request external review through New York's Department of Financial Services within 4 months of the final denial. New York's external review is binding on insurers and has strong success rates for oncology drugs with solid clinical evidence.

Start today: Call Humana Member Services (number on your ID card) to confirm Retevmo's formulary status and request prior authorization forms for your oncologist.

Table of Contents

When Alternatives Make Sense

Before pursuing a lengthy prior authorization battle for Retevmo, it's worth understanding when Humana's formulary alternatives might be clinically appropriate. This isn't about settling for less effective treatment—it's about strategic timing and understanding your options.

Consider formulary alternatives first if:

  • You're newly diagnosed and haven't tried any RET inhibitor yet
  • Your oncologist confirms that pralsetinib (Gavreto) would be equally effective for your specific RET alteration
  • You need treatment to start immediately while pursuing a formulary exception for Retevmo
  • Previous insurance covered a different RET inhibitor that you tolerated well

Don't consider alternatives if:

  • You've already failed pralsetinib or cabozantinib/vandetanib
  • You have specific contraindications to other RET inhibitors (drug interactions, comorbidities)
  • Your tumor has known resistance mutations that favor selpercatinib specifically

Typical Formulary Alternatives

Humana's 2025 formulary policies include several RET-targeting options, though specific tier placement varies by plan type:

Selective RET Inhibitors

Pralsetinib (Gavreto) is often the primary formulary alternative to Retevmo. Both drugs target RET fusion-positive NSCLC and RET-mutant medullary thyroid cancer with similar efficacy rates (ORR 69-89%). Key differences include:

  • Toxicity profile: Pralsetinib has higher rates of neutropenia (20% grade 3/4) vs. Retevmo's hypertension (9%)
  • Dosing: Pralsetinib 400mg once daily vs. Retevmo 160mg twice daily
  • Prior authorization: Both require PA, but pralsetinib may have fewer step therapy requirements

Multi-Kinase Inhibitors (for MTC)

For medullary thyroid cancer specifically, Humana covers:

  • Cabozantinib (Cabometyx) - Often preferred first-line option
  • Vandetanib (Caprelsa) - Requires REMS program enrollment

These older agents have more side effects but established formulary positions. The LIBRETTO-531 trial showed Retevmo superior to these multi-kinase inhibitors (PFS hazard ratio 0.38), making them reasonable stepping stones for prior authorization purposes.

From our advocates: "We've seen success when patients start with the formulary RET inhibitor while simultaneously filing a formulary exception for Retevmo. This keeps treatment moving and provides real-world evidence if the first-line option causes intolerable side effects—strengthening the medical necessity case."

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must get approval before filling Humana formulary or call Member Services Humana Drug Lists
RET Testing Required FDA-approved diagnostic confirming RET alteration FoundationOne CDx, Oncomine Dx, or TSO Comprehensive FDA Companion Diagnostics
Specialty Pharmacy Must use designated pharmacy network Humana specialty pharmacy list Provider Portal
Appeals Deadline 65 days for Medicare Part D Notice of denial letter CMS Part D Appeals
NY External Review 4 months after final internal denial DFS external appeal forms NY DFS Appeals

Step-by-Step: Fastest Path to Approval

1. Confirm Your Plan's Formulary Status

Who does it: You or your clinic staff
Timeline: 15 minutes
Call Humana Member Services (number on your insurance card) and ask: "Is Retevmo covered on my formulary? What tier? Are there any restrictions like prior authorization or step therapy?"

2. Gather Required Documentation

Who does it: Your oncologist's office
Timeline: 1-3 days
Collect: RET testing results (FoundationOne CDx or equivalent FDA-approved test), pathology reports, treatment history, and current clinical notes.

3. Submit Prior Authorization Request

Who does it: Your oncologist
Timeline: 72 hours for standard decision
Submit via Humana provider portal or fax to 877-486-2621. Include medical necessity letter (see checklist below).

4. Request Expedited Review if Urgent

Who does it: You or your oncologist
Timeline: 24 hours for expedited decision
If waiting could seriously jeopardize your health, explicitly request expedited review in your submission.

5. Use Transition Coverage if Available

Who does it: Pharmacy/Humana
Timeline: Up to 31 days
New members may get temporary coverage while PA is processed under Humana's transition policy.

6. File Internal Appeal if Denied

Who does it: You or your representative
Timeline: Must file within 65 days; 7-day decision
Submit additional clinical evidence addressing specific denial reasons.

7. Pursue New York External Review

Who does it: You
Timeline: File within 4 months; decision in 30 days (72 hours if expedited)
File through NY DFS external appeal process - this decision is binding on Humana.

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
"RET testing not FDA-approved" Resubmit with FoundationOne CDx or Oncomine Dx results FDA-cleared companion diagnostic report
"Step therapy not completed" Document contraindications to formulary alternatives Medical records showing drug interactions, prior failures, or toxicities
"Not medically necessary" Provide NCCN guidelines and clinical evidence NCCN Guidelines showing Category 1 recommendation for RET+ tumors
"Experimental/investigational" Cite FDA approval and established use FDA label and peer-reviewed efficacy data from LIBRETTO trials

Appeals Playbook for New York

Internal Appeals (Required First Step)

Timeline: 65 days to file, 7 days for standard decision
How to file: Call Humana Member Services, submit via online portal, or mail written request
Required: Copy of denial letter, additional medical records, updated physician statement

New York External Review (Unique State Advantage)

New York offers one of the strongest external review systems in the country. After exhausting Humana's internal appeals:

Timeline: 4 months to file after final internal denial
Cost: Maximum $25 (waived for financial hardship)
Decision: Binding on Humana, typically 30 days (72 hours expedited)
File through: NY DFS Portal or mail forms

Key advantages for oncology drugs:

  • Independent medical experts review your case
  • Strong track record overturning denials for cancer treatments with solid evidence
  • Expedited review available if delay risks your health
  • Searchable database of past decisions provides precedent
Tip: New York's external reviewers often reference medical literature in their decisions. Include recent peer-reviewed studies supporting Retevmo's efficacy in your specific cancer type.

Medical Necessity Letter Checklist

Your oncologist's letter should include these specific elements for Retevmo:

Clinical Documentation:

  • ✓ Exact cancer diagnosis with staging (e.g., "Stage IV RET fusion-positive NSCLC")
  • ✓ RET alteration details from FDA-approved testing
  • ✓ Performance status and treatment goals
  • ✓ Prior therapies tried and outcomes (progression dates, toxicities)

Medical Necessity Justification:

  • ✓ "In my medical judgment, Retevmo is medically necessary for this patient"
  • ✓ Why formulary alternatives are inappropriate (contraindications, prior failures, expected inferior efficacy)
  • ✓ Reference to NCCN Guidelines Category 1 recommendation
  • ✓ Expected clinical benefit and monitoring plan

Supporting Evidence:

  • ✓ FDA label indication match
  • ✓ Peer-reviewed literature (LIBRETTO-001/531 trial data)
  • ✓ Professional society guidelines (ASCO, NCCN)

For comprehensive support with prior authorization documentation, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

Costs & Savings Options

Manufacturer Support:

  • Lilly Oncology Patient Support offers copay assistance up to $25,000/year for eligible patients
  • Patient assistance programs for uninsured or underinsured patients

Medicare-Specific Programs:

  • Extra Help (Low-Income Subsidy) for prescription costs
  • State Pharmaceutical Assistance Programs (SPAP) in New York

Foundation Grants:

Note: Manufacturer copay cards typically don't work with Medicare, but foundation grants often do. Apply early as funds are limited.

FAQ

How long does Humana prior authorization take in New York?
Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests (for urgent medical needs) are decided within 24 hours.

What if Retevmo is completely non-formulary on my plan?
You can request a formulary exception. This requires your doctor to document that formulary alternatives are not medically appropriate. New York's external review system has successfully overturned many non-formulary denials for cancer drugs.

Can I get expedited appeals in New York?
Yes. Both Humana and New York's external review process offer expedited timelines when delays could seriously jeopardize your health. External expedited decisions come within 72 hours (24 hours for urgent drug denials).

Does step therapy apply if I tried other RET inhibitors outside New York?
Medical records from any state showing prior treatment failures should satisfy step therapy requirements. Ensure your oncologist includes detailed documentation of previous therapies and outcomes.

What happens if I move to New York mid-treatment?
Humana's transition policy typically provides temporary coverage for continuing medications while you establish care with new providers. Contact Member Services immediately when you move.

How do I find New York-specific help with appeals?
Community Health Advocates offers free assistance at 888-614-5400. The NY Department of Financial Services also provides consumer assistance.

What's the success rate for external appeals in New York?
While specific statistics for Retevmo aren't published, New York's external review system has historically favored patients in cases where strong clinical evidence supports medical necessity, particularly for FDA-approved cancer treatments.

Can my doctor do a peer-to-peer review with Humana?
Yes. Your oncologist can request to speak directly with Humana's medical director. This often resolves denials faster than written appeals, especially when clinical nuances need explanation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance plan directly. For personalized assistance with complex prior authorization and appeals processes, Counterforce Health provides specialized support for patients navigating insurance coverage for specialty medications.

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