By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (Selpercatinib) Covered by Humana in Virginia: Forms, Timelines & Appeals Process

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

Fastest path to approval: Submit a prior authorization request through Humana's provider portal with RET alteration test results, diagnosis codes, and prior treatment history. If denied, you have 65 days to appeal and can request expedited review for urgent cases (decided within 72 hours). Virginia residents can pursue external review through the State Corporation Commission's Bureau of Insurance after exhausting internal appeals.

First step today: Contact your prescriber to initiate the PA process and gather required documentation including genetic test results confirming RET alterations.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Basics
  6. Submission Process & Forms
  7. Appeals Process in Virginia
  8. Common Denial Reasons & Solutions
  9. External Review Options
  10. FAQ

Humana Plan Types & Coverage Implications

Retevmo (selpercatinib) coverage varies significantly across Humana's plan types in Virginia:

Medicare Advantage Plans: Most Humana members in Virginia have Medicare Advantage coverage, where Retevmo falls under Part B (if administered in clinical settings) or Part D (for take-home oral formulations). Prior authorization is typically required for both.

Commercial Plans: Less common in Virginia's market but follow similar specialty drug protocols with network-specific formulary placement.

Note: Retevmo requires specialty pharmacy dispensing regardless of plan type, which affects where you can fill prescriptions and may influence coverage decisions.

Formulary Status & Tier Placement

Based on current research, Retevmo is not explicitly listed on Humana's public formulary documents, requiring members to verify coverage through their specific plan's Prescription Drug Guide.

Key Coverage Points:

  • Non-formulary status likely: Requires formulary exception request
  • Specialty tier placement: When covered, typically placed on highest cost-sharing tier
  • Alternative options: Gavreto (pralsetinib) may have different formulary status

To verify your plan's specific coverage, use Humana's drug list lookup tool or contact member services directly.

Prior Authorization Requirements

Humana requires prior authorization for specialty oncology drugs like Retevmo. The approval process focuses on these clinical criteria:

Required Documentation

Requirement Details Source Document
RET Alteration Confirmation FDA-approved test showing RET fusion/mutation Genetic test report
Diagnosis Codes ICD-10 codes for qualifying cancers Medical records
Prior Treatment History Documentation of previous therapies tried/failed Treatment timeline
Clinical Notes Prescriber assessment of medical necessity Provider documentation

FDA-Approved Testing Methods

The FDA recognizes several testing approaches for RET alterations:

  • Next-generation sequencing (NGS): Preferred method, especially RNA-based NGS
  • Fluorescence in situ hybridization (FISH): Rapid results with high sensitivity
  • RT-PCR: Moderate to high sensitivity but limited fusion partner detection
Tip: Tissue testing is preferred over liquid biopsy, as up to 30% of RET alterations may be missed in blood-only testing.

Specialty Pharmacy Network

Retevmo is dispensed through CenterWell Specialty Pharmacy, Humana's preferred specialty network partner.

Dispensing Requirements:

  • Dosage verification (40mg, 80mg, 120mg, or 160mg formulations)
  • Renal function documentation (creatinine or GFR)
  • Liver function status
  • Biomarker confirmation of RET-positive status
  • Previous therapy history with discontinuation reasons

Standard Dosing: 160mg twice daily is typical, though doses may be adjusted based on tolerability and organ function.

Cost-Share Basics

Retevmo's cash price ranges from $23,000-$26,000 per 30-day supply, making insurance coverage critical for most patients.

Typical Cost-Sharing Structure:

  • Specialty tier copay/coinsurance: Often 25-33% of drug cost
  • Deductible application: May apply before copay benefits
  • Out-of-pocket maximum: Annual limit provides eventual cost protection
Important: These are educational estimates only. Your actual costs depend on your specific plan design and cannot be determined without a benefits verification.

Submission Process & Forms

For Non-Formulary Coverage

Use the "Request for Medicare Prescription Drug Coverage Determination" form available through Humana's member portal.

Submission Options:

  • Online: Humana provider portal (fastest processing)
  • Fax: 877-486-2621
  • Phone: 800-555-CLIN (2546) for providers

Required Supporting Statement

Your prescriber must explain why:

  • All formulary alternatives would be less effective
  • Formulary drugs would cause adverse effects
  • Standard restrictions (step therapy, quantity limits) are inappropriate

Appeals Process in Virginia

Internal Appeals Timeline

Appeal Type Decision Timeline When to Use
Standard Appeal 7 days (Part D), 30 days (Part C) Most denials
Expedited Appeal 72 hours Health could be seriously jeopardized
Filing Deadline 65 days from denial notice All appeals

Step-by-Step Appeal Process

  1. Submit written appeal within 65 days of denial
  2. Request expedited review if urgent (include prescriber statement)
  3. Provide supporting documentation (test results, clinical notes)
  4. Await Humana's decision within applicable timeline
  5. Proceed to external review if denied (within 60 days)

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Missing RET test results Submit FDA-approved genetic testing NGS, FISH, or RT-PCR report
Wrong tumor type Clarify FDA-approved indications Updated diagnosis with ICD-10 codes
Insufficient prior therapy Document treatment failures Complete treatment timeline
QT/drug interaction concerns Address monitoring plan Cardiac assessment, medication review

External Review Options

If Humana upholds its denial, Virginia residents have strong external review rights through the State Corporation Commission's Bureau of Insurance.

Virginia External Review Process

Timeline: 120 days after final internal denial to file Standard Review: 45 days for decision Expedited Review: 72 hours for urgent cases Cost: Free to consumers

Required Forms:

  • Form 216-A (External Review Request)
  • Authorized Representative form (if applicable)
From our advocates: We've seen Virginia's external review process work particularly well for oncology cases where the clinical evidence is strong but the initial reviewer missed key details. The independent medical experts often have more specialized knowledge than internal reviewers.

When External Review Applies

Virginia's process covers denials based on:

  • Medical necessity determinations
  • Experimental/investigational treatment classifications
  • Clinical judgment issues

Contact Information: Virginia State Corporation Commission Bureau of Insurance 1-877-310-6560 (Consumer Services)

When to Escalate Further

If external review doesn't resolve your case, additional options include:

  • Employer HR department (for self-funded plans)
  • Virginia Poverty Law Center for legal assistance
  • Office of the Managed Care Ombudsman for HMO-specific issues

The platform developed by Counterforce Health can help streamline the appeals process by automatically generating evidence-backed appeals letters that address payer-specific requirements and cite relevant medical literature. This type of systematic approach often improves approval rates by ensuring all necessary clinical and procedural elements are addressed comprehensively.

FAQ

How long does Humana prior authorization take for Retevmo in Virginia? Standard PA decisions are made within 72 hours for Part D drugs. Expedited requests (when health is at risk) are decided within 24 hours.

What if Retevmo is non-formulary on my Humana plan? Submit a formulary exception request with your prescriber's supporting statement explaining why formulary alternatives won't work for your specific case.

Can I request an expedited appeal if my initial PA is denied? Yes, if waiting for a standard appeal timeline could seriously jeopardize your health. Your prescriber must provide a statement supporting the urgency.

Does step therapy apply to Retevmo in Virginia? Step therapy requirements vary by plan. If applicable, you can request an exception by documenting why previous therapies failed or would be inappropriate.

What happens if I miss the 65-day appeal deadline? You may lose your right to internal appeal, but Virginia's external review process may still be available. Contact the Bureau of Insurance for guidance on your specific situation.

How much does external review cost in Virginia? External review through Virginia's Bureau of Insurance is completely free to consumers.

For patients and clinicians navigating complex coverage decisions, platforms like Counterforce Health offer specialized tools that help transform insurance denials into targeted, evidence-backed appeals by analyzing payer policies and generating comprehensive rebuttal letters aligned with each plan's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult your healthcare provider and insurance plan directly for personalized guidance. For additional help with insurance appeals in Virginia, contact the State Corporation Commission's Bureau of Insurance at 1-877-310-6560.

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