By Counterforce Health Team in Rezlidhia (olutasidenib) —

How to Get Rezlidhia (Olutasidenib) Covered by Humana in Illinois: PA Requirements, Appeals & Forms

Answer Box: Getting Rezlidhia Covered by Humana in Illinois

Rezlidhia (olutasidenib) requires prior authorization from Humana and is likely Tier 4 (specialty) if covered. Your oncologist must document IDH1-mutated relapsed/refractory AML and submit evidence of medical necessity. If denied, Illinois patients have 65 days to appeal internally, then 30 days for external review through the Illinois Department of Insurance. Start today: Check your plan's formulary at humana.com/pharmacy/medicare-drug-list, then have your prescriber submit the PA request with genetic testing results and prior therapy documentation.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Considerations
  6. Submission Process & Forms
  7. Appeals Process in Illinois
  8. Common Denial Reasons & Solutions
  9. When to Escalate
  10. FAQ

Plan Types & Coverage Implications

Humana offers several plan types in Illinois, each with different coverage rules for specialty oncology drugs like Rezlidhia:

Medicare Advantage Plans: Humana's primary offering in Illinois, covering both medical services (Part C) and prescription drugs (Part D). These plans use formularies with tiered pricing structures and require prior authorization for specialty medications.

Dual Special Needs Plans (D-SNP): For patients with both Medicare and Medicaid, offering enhanced benefits but following similar PA requirements for high-cost oncology drugs.

Note: Humana's Medicare Advantage PA denial rate is approximately 3.5% (2023), among the lowest of major insurers, but denials often stem from incomplete documentation rather than medical necessity disputes.

Formulary Status & Tier Placement

Current Status: Rezlidhia (olutasidenib) is not explicitly listed in available Humana Medicare Advantage formulary excerpts for 2024-2025, indicating it may require a formulary exception or falls under specialty tier coverage that varies by plan.

Likely Tier Placement: If covered, Rezlidhia would typically be placed on Tier 4 (Specialty Tier) due to its:

  • High cost (~$32,000/month list price)
  • Oncology specialty classification
  • Limited distribution network requirements

Formulary Verification Steps:

  1. Search your specific plan's drug list at humana.com/pharmacy/medicare-drug-list
  2. Enter "Rezlidhia" or "olutasidenib" in the search tool
  3. Call Humana member services (number on your ID card) for confirmation

Prior Authorization Requirements

Humana requires prior authorization for Rezlidhia, with coverage policy effective through November 19, 2025. Your oncologist must document:

Medical Necessity Criteria

Requirement Documentation Needed
Diagnosis Relapsed/refractory AML with susceptible IDH1 mutation
Age Patient ≥18 years old
Genetic Testing FDA-approved IDH1 mutation test results
Prescriber Board-certified oncologist or hematologist
Prior Therapies Documentation of previous treatments and outcomes
Monitoring Plan Laboratory monitoring schedule for differentiation syndrome

Required Documentation

  • Complete medical history with ICD-10 codes
  • IDH1 mutation testing report from approved laboratory
  • Previous treatment records showing failure/intolerance
  • Current laboratory values (CBC, comprehensive metabolic panel, LFTs)
  • Proposed monitoring schedule per FDA prescribing information

Specialty Pharmacy Network

Rezlidhia is distributed exclusively through limited specialty pharmacies authorized by the manufacturer:

Authorized Dispensing Partners:

  • Optime Care: 1-888-287-2017
  • Biologics by McKesson: Contact via prescriber
  • Additional integrated or in-office dispensing pharmacies may be available

Dispensing Process:

  1. Obtain PA approval from Humana first
  2. Contact authorized pharmacy directly with insurance details
  3. Provide prescriber information and patient demographics
  4. Coordinate delivery after PA confirmation
Important: No Humana-specific preferred pharmacy partners have been identified for Rezlidhia, so patients can use any manufacturer-authorized specialty pharmacy.

Cost-Share Considerations

Tier 4 Specialty Costs: If covered as specialty tier, expect:

  • Higher coinsurance (typically 25-33% of drug cost)
  • Potential deductible application
  • Monthly out-of-pocket maximums may apply

Financial Assistance Options:

  • Manufacturer patient assistance programs
  • Medicare Extra Help/Low Income Subsidy
  • State pharmaceutical assistance programs
  • Cancer-specific foundation grants

Note: This is educational information only. Consult your plan documents for specific cost-sharing details.

Submission Process & Forms

For Non-Formulary Coverage

If Rezlidhia is not on your plan's formulary, request a formulary exception using Humana's "Request for Medicare Prescription Drug Coverage Determination Form".

Key Form Sections:

  • Select "I need a drug not on the plan's list (formulary exception)"
  • Attach prescriber's supporting statement with clinical rationale
  • Include documentation of formulary alternatives tried/failed

Submission Methods

Timeline: Standard decisions within 72 hours; expedited (24 hours) if delay risks serious harm.

Appeals Process in Illinois

Illinois provides strong patient rights for insurance denials with specific timelines:

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Timeline: Decision within 15 business days (24 hours if expedited)
  • Who Can Appeal: Patient, prescriber, or authorized representative

External Review (Independent)

  • Deadline: 30 days from final internal denial (shorter than many states)
  • Process: Illinois Department of Insurance assigns Independent Review Organization
  • Cost: Free to patients; insurer pays review costs
  • Timeline: Decision within 5 business days after IRO receives materials
  • Reviewer: Board-certified physician with relevant expertise

Illinois-Specific Resources

  • Illinois Department of Insurance: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145
  • External Review Forms: Available at Illinois DOI website
Critical: Illinois' 30-day external review deadline is shorter than most states. Act promptly after internal appeal denial.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
IDH1 mutation not documented Submit genetic testing report FDA-approved IDH1 mutation test results
Off-label use Cite FDA approval for relapsed/refractory AML FDA prescribing information
Lack of monitoring plan Provide detailed monitoring schedule Laboratory monitoring protocol per FDA guidelines
Non-oncology prescriber Transfer to hematologist/oncologist Board certification documentation
Insufficient prior therapy documentation Compile complete treatment history Medical records showing previous therapies and outcomes

When to Escalate

Contact Illinois Department of Insurance if:

  • Internal appeals are delayed beyond 15 business days
  • Humana fails to provide required appeal forms
  • You need help understanding your rights

File External Review if:

  • Internal appeal is denied
  • You believe the denial lacks medical merit
  • An independent physician review could support coverage

For complex cases, consider contacting Counterforce Health, which specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Rezlidhia.

FAQ

How long does Humana prior authorization take in Illinois? Standard PA decisions are made within 72 hours. Expedited requests (when delay could harm health) are processed within 24 hours.

What if Rezlidhia is non-formulary on my plan? Request a formulary exception using Humana's coverage determination form. Your prescriber must document that all formulary alternatives are less effective or cause adverse effects.

Can I request an expedited appeal in Illinois? Yes, if a delay would seriously jeopardize your health. Mark the expedited box on appeal forms and have your prescriber provide supporting documentation.

Does step therapy apply to Rezlidhia? Step therapy may apply depending on your plan. Your oncologist can request an exception if you've already failed standard AML therapies or if they would be inappropriate.

What counts as medical necessity for Rezlidhia? FDA-approved indication (relapsed/refractory AML with IDH1 mutation), appropriate prescriber (oncologist), documented mutation testing, and evidence that standard therapies have failed or are contraindicated.

How much does Rezlidhia cost with Humana coverage? Costs vary by plan tier and deductible status. Specialty tier drugs typically have 25-33% coinsurance. Contact Humana for your specific cost-sharing details.

Clinician Corner: Medical Necessity Letter Checklist

When submitting prior authorization requests for Rezlidhia, include:

Essential Clinical Elements:

  • Patient's complete AML history with ICD-10 codes
  • IDH1 mutation testing results (specific mutation type)
  • Previous therapy details: drugs used, doses, durations, reasons for discontinuation
  • Current disease status and treatment goals
  • Proposed dosing: 150 mg orally twice daily
  • Monitoring plan for differentiation syndrome and hepatotoxicity

Supporting Evidence:

Counterforce Health helps patients and clinicians navigate complex prior authorization processes for specialty medications. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that align with payer-specific requirements. Learn more about our services.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and appeal processes. It is not medical advice. Always consult your healthcare provider for medical decisions and your insurance company for coverage determinations. Coverage policies and appeal procedures may change; verify current requirements with official sources.

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