By Counterforce Health Team in Revcovi (elapegademase) —

How to Get Revcovi (Elapegademase) Approved by Humana in Florida: Complete Prior Authorization Guide

Quick Start: Getting Revcovi Covered by Humana in Florida

Revcovi (elapegademase) requires prior authorization from Humana in Florida. Start by confirming your plan type (Medicare Advantage vs. commercial) and verifying Revcovi is on your formulary tier. You'll need confirmed ADA-SCID diagnosis, specialist oversight, and a detailed medical necessity letter. Submit through Humana's provider portal or specialty pharmacy network. If denied, Florida residents have 180 days for internal appeals and 4 months for external review through the Department of Financial Services.

First step today: Call the number on your Humana ID card to confirm benefit type (pharmacy vs. medical) and required specialty pharmacy network.

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 Tracking
  6. Typical Approval Timelines
  7. If You Need to Provide More Information
  8. If Your Request Is Denied
  9. Renewal and Reauthorization
  10. Printable Checklist
  11. Frequently Asked Questions

What This Guide Covers

This guide helps patients with ADA-SCID (adenosine deaminase severe combined immunodeficiency) and their healthcare teams navigate Humana's prior authorization process for Revcovi (elapegademase) in Florida. Whether you have Medicare Advantage, commercial insurance, or Medicaid through Humana, this step-by-step approach can help you get coverage approved faster and avoid common delays.

Who this helps:

  • Patients diagnosed with ADA-SCID needing enzyme replacement therapy
  • Caregivers managing insurance approvals for family members
  • Clinicians submitting prior authorization requests
  • Specialty pharmacies coordinating coverage

What you can expect: With proper documentation, most Humana prior authorizations for rare disease treatments like Revcovi are approved within 30 days. Appeals in Florida have a meaningful success rate when supported by strong clinical evidence.

Before You Start: Verify Your Coverage

Step 1: Confirm Your Humana Plan Type

Call the member services number on your Humana ID card and ask:

  • "Is Revcovi (elapegademase) covered under my plan?"
  • "Is it under the pharmacy benefit or medical benefit?"
  • "What tier is it on and what are my cost-sharing obligations?"

Step 2: Check Formulary Status

Humana typically places Revcovi on a specialty tier with higher cost-sharing. Use Humana's online drug list tool to verify:

  • Formulary tier placement
  • Prior authorization requirements (PA)
  • Specialty pharmacy network requirements
  • Any step therapy or quantity limits

Step 3: Identify Your Specialty Pharmacy Network

Humana requires Revcovi to be dispensed through approved specialty pharmacies, typically CenterWell Specialty Pharmacy or other contracted providers.

Gather Required Documentation

Core Clinical Requirements

Requirement What You Need ICD-10 Code
ADA-SCID Diagnosis Genetic testing or ADA enzyme activity <1% of normal D81.31 or D81.3
Specialist Oversight Immunologist, hematologist/oncologist, or ADA-SCID expert -
Prior Therapies Documentation of why HSCT/gene therapy isn't suitable -
Baseline Labs Lymphocyte subsets, ADA activity, dAXP levels -

Essential Documents to Collect

From your medical records:

  • Confirmed ADA-SCID diagnosis with genetic or enzymatic testing
  • Recent lymphocyte subset analysis showing severe T-cell deficiency
  • Infection history and hospitalizations
  • Prior therapy attempts (if any)
  • Current weight and dosing calculations

From your insurance:

Tip: The manufacturer's Chiesi Total Care program can assist with PA form completion and submission tracking.

Submit Your Prior Authorization Request

For Pharmacy Benefit (Most Common)

  1. Download the correct PA form from Humana's provider portal
  2. Complete all sections including:
    • Drug: Revcovi (elapegademase-lvlr)
    • Diagnosis: ADA-SCID with ICD-10 code D81.31
    • Dosing: Typically 0.4 mg/kg/week IM, divided into twice-weekly injections
    • Prescriber NPI and specialty credentials
  3. Attach supporting documentation:
    • Medical necessity letter from specialist
    • ADA enzyme activity results
    • Genetic testing report (if available)
    • Lymphocyte subset analysis
    • Clinical notes documenting infection history
  4. Submit via preferred channel:
    • Electronic: Through EHR or Humana's PA portal
    • Fax: Use number provided on PA form
    • Phone: Contact Humana clinical intake team for urgent cases

Medical Necessity Letter Template

Your specialist should include these key elements:

Patient Information & Diagnosis

  • Confirmed ADA-SCID with supporting lab values
  • Clinical presentation and infection history
  • Why curative options (HSCT/gene therapy) aren't appropriate

Treatment Rationale

  • Requested dose: [X] mg/kg twice weekly IM
  • Expected monitoring plan (ADA activity, dAXP levels)
  • Treatment goals and success metrics

Specialist Attestation

  • Prescriber credentials in immunology/hematology
  • Commitment to ongoing monitoring
  • Safety assessment (platelet count ≥50,000/μL for IM injection)

Follow-Up and Tracking

When to Call Humana

  • Day 3-5: Confirm PA was received and assigned a case number
  • Day 10-14: Check status if no initial response
  • Day 20: Escalate if approaching deadline without decision

Sample Phone Script

"I'm calling about prior authorization case number [X] for Revcovi for my patient with ADA-SCID. Can you tell me the current status and if any additional information is needed?"

Document all calls with date, representative name, and case notes.

Typical Approval Timelines

Plan Type Standard Timeline Expedited Timeline
Medicare Advantage 30 days 72 hours (urgent)
Commercial 15-30 days 72 hours (urgent)
Medicaid 30 days 3 business days

What speeds approval:

  • Complete documentation on first submission
  • Specialist-authored medical necessity letter
  • Clear ADA-SCID diagnosis with lab confirmation

What slows approval:

  • Missing clinical notes or lab results
  • Non-specialist prescriber without consultation documentation
  • Unclear dosing rationale or monitoring plan
Note: Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters and plan policies to create evidence-backed rebuttals.

If You Need to Provide More Information

Humana may request additional clinical details. Common requests include:

"Medical necessity not established"

  • Provide detailed infection history
  • Include lymphocyte trend data
  • Explain why patient isn't a transplant candidate

"Alternative therapies not tried"

  • Document contraindications to HSCT
  • Explain gene therapy availability/eligibility
  • Include prior Adagen use (if applicable)

"Dosing exceeds guidelines"

  • Reference FDA labeling for individualized dosing
  • Provide trough ADA activity and dAXP levels
  • Justify twice-weekly vs. weekly administration

Submit additional information promptly to avoid delays. Most requests have 7-14 day response deadlines.

If Your Request Is Denied

Common Denial Reasons & Solutions

Denial Reason How to Appeal
Not medically necessary Submit peer-reviewed studies on ADA-SCID mortality without treatment
Experimental/investigational Cite FDA approval and established treatment guidelines
Step therapy not met Document that Revcovi is the only FDA-approved ERT for ADA-SCID
Missing specialist requirement Provide immunologist consultation or referral

Florida Appeal Process

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for Humana's decision
  • How to file: Follow instructions on denial letter or call member services

External Review (If Internal Appeal Denied)

Expedited Appeals

  • Available when waiting could seriously harm health
  • Decision within 72 hours for urgent cases
  • Can file expedited internal and external appeals simultaneously

Peer-to-Peer Review Request

If denied, request a peer-to-peer (P2P) review where your specialist speaks directly with Humana's medical director:

"I'd like to request a peer-to-peer review for case [X]. My immunologist needs to speak with your medical director about this ADA-SCID patient."

P2P reviews often resolve denials when the clinical picture is clearly explained by a specialist.

Renewal and Reauthorization

Humana typically approves Revcovi for 12-month periods. Start renewal 30-60 days before expiration.

What to Include in Renewal Requests

Clinical Response Data

  • Infection frequency since starting therapy
  • Lymphocyte count improvements
  • ADA activity and dAXP trend data
  • Growth and development progress (pediatric patients)

Updated Information

  • Current weight and dose adjustments
  • Any adverse events or tolerability issues
  • Continued specialist oversight documentation
  • Ongoing monitoring plan

Treatment Continuation Rationale

  • Why enzyme replacement remains necessary
  • HSCT/gene therapy status update
  • Long-term treatment goals

Planning renewals early prevents treatment gaps that could be dangerous for immunodeficient patients.

Printable Checklist

Before Starting:

  • Confirm Humana plan type and formulary status
  • Identify required specialty pharmacy network
  • Download correct PA form from Humana provider portal

Documentation to Gather:

  • ADA-SCID diagnosis with ICD-10 code D81.31
  • ADA enzyme activity <1% normal or genetic testing
  • Lymphocyte subset analysis showing SCID
  • Specialist credentials (immunology/hematology)
  • Medical necessity letter with dosing rationale
  • Prior therapy documentation
  • Current weight for dose calculation

Submission:

  • Complete PA form with all required fields
  • Attach clinical documentation
  • Submit via Humana's preferred method
  • Document case number for tracking

Follow-up:

  • Call day 3-5 to confirm receipt
  • Check status at day 10-14
  • Respond promptly to any information requests
  • Plan renewal 30-60 days before expiration

Frequently Asked Questions

How long does Humana prior authorization take in Florida? Standard timeline is 30 days for Medicare Advantage and 15-30 days for commercial plans. Expedited reviews are available in urgent situations with decisions within 72 hours.

What if Revcovi is not on my Humana formulary? You can request a formulary exception through Humana's standard exception process. Your specialist will need to provide strong medical necessity documentation explaining why Revcovi is essential for your ADA-SCID treatment.

Can I request an expedited appeal if denied? Yes, if waiting for standard appeal timing could seriously harm your health. Both expedited internal appeals and expedited external reviews are available in Florida for urgent medical situations.

Does step therapy apply to Revcovi? Step therapy is generally not applied since Revcovi is the only FDA-approved enzyme replacement therapy for ADA-SCID. However, Humana may require documentation about why curative options like HSCT aren't appropriate.

What's the difference between pharmacy and medical benefit coverage? Pharmacy benefit typically involves specialty pharmacy dispensing with home delivery. Medical benefit covers office or hospital administration. Check with Humana to determine which applies to your situation.

How much does Revcovi cost with Humana coverage? Cost depends on your plan's specialty tier copay or coinsurance. Revcovi typically costs around $11,851 per vial before insurance. Contact Chiesi Total Care about potential copay assistance programs.

What if my doctor isn't an immunologist? Humana typically requires specialist oversight for Revcovi. Your primary care doctor can refer you to an immunologist or hematologist/oncologist, or document consultation with a specialist for the PA.

Can I appeal to the state if Humana denies coverage? Yes, Florida residents can file external reviews through the Department of Financial Services after exhausting internal appeals. This independent review process is free and can overturn insurer denials.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. The platform identifies specific denial reasons and drafts point-by-point responses aligned to each payer's own coverage rules, significantly improving approval rates for complex specialty medications like Revcovi.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider about treatment decisions and contact your insurance company directly for coverage verification. For assistance with insurance complaints in Florida, contact the Department of Financial Services at 1-877-MY-FL-CFO.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.