How to Get Rezlidhia (Olutasidenib) Covered by Humana in Washington: Coding, Appeals, and Prior Authorization Guide
Answer Box: Getting Rezlidhia Covered by Humana in Washington
Eligibility: Adults with relapsed/refractory AML harboring a susceptible IDH1 mutation. Fastest path: Submit prior authorization with IDH1 mutation test results, comprehensive medical necessity letter, and proper ICD-10 coding (C92.02 for relapsed AML). First step today: Call Humana Clinical Pharmacy Review at 800-555-CLIN (2546) to confirm current PA requirements and check formulary status. If denied, you have 65 days to appeal and can request external review through Washington's Independent Review Organization process.
Table of Contents
- Understanding Rezlidhia Coverage Under Humana
- ICD-10 Coding for Relapsed/Refractory AML
- NDC and Billing Requirements
- Step-by-Step Prior Authorization Process
- Common Denial Reasons & How to Fix Them
- Appeals Process in Washington
- Medical Necessity Documentation
- Cost Assistance and Support
- FAQ
Understanding Rezlidhia Coverage Under Humana
Rezlidhia (olutasidenib) is a specialty oral medication that requires prior authorization under most Humana Medicare plans. As an IDH1 inhibitor for relapsed/refractory AML, it typically falls under the pharmacy benefit (Part D) rather than the medical benefit, with an estimated cost of approximately $32,000 per month.
Coverage at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization | Required for all Humana plans | Humana Provider Portal |
| IDH1 Mutation Testing | FDA-approved test confirming susceptible mutation | Your oncologist's molecular testing lab |
| Formulary Status | May be non-formulary; exception needed | Humana drug list or member portal |
| Appeals Deadline | 65 days from denial notice | Humana Member Appeals |
ICD-10 Coding for Relapsed/Refractory AML
Proper diagnosis coding is critical for approval. The primary codes for relapsed AML include:
- C92.02: Acute myeloblastic leukemia, in relapse (most common)
- C92.52: Acute myelomonocytic leukemia, in relapse
- C92.A2: Acute myeloid leukemia with multilineage dysplasia, in relapse
For refractory disease (not achieving remission), use codes ending in "0" instead of "2". Your oncologist must document both the AML subtype and relapsed/refractory status in medical records to support the coding.
Clinical Note: The ICD-10 code must align with your pathology reports and bone marrow biopsy results. Inconsistent coding between diagnosis and supporting documentation is a common cause of denials.
NDC and Billing Requirements
Rezlidhia uses NDC 71332-005-01 for the 150 mg capsules. Since it's an oral medication, it's billed through the pharmacy benefit rather than requiring HCPCS J-codes typically used for physician-administered drugs.
Key Billing Details:
- Strength: 150 mg capsules
- Typical dosing: 150 mg twice daily (300 mg total daily dose)
- NDC: 71332-005-01
- Manufacturer: Rigel Pharmaceuticals
No permanent HCPCS J-code exists for olutasidenib as of 2025, confirming its status as a pharmacy benefit medication.
Step-by-Step Prior Authorization Process
1. Verify Coverage (Day 1)
Who: You or your clinic Action: Call Humana at 800-555-CLIN (2546) to confirm PA requirements Documents needed: Member ID, prescriber information Timeline: Same day
2. Gather Required Documentation (Days 1-3)
Who: Your oncology team Documents needed:
- IDH1 mutation test results (FDA-approved assay)
- Bone marrow biopsy confirming AML diagnosis
- Treatment history showing relapsed/refractory status
- Current performance status assessment
3. Submit Prior Authorization (Day 3-5)
Who: Your prescriber How: Humana provider portal or fax to 877-486-2621 Timeline: Humana commits to decisions within one business day for 95% of complete electronic submissions
4. Follow Up (Day 6-7)
Who: You or your clinic Action: Confirm receipt and track status through member portal Backup: Call Clinical Pharmacy Review team if no response
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn |
|---|---|
| IDH1 mutation not documented | Submit FDA-approved molecular testing report with clear mutation status |
| Insufficient prior therapy documentation | Provide detailed treatment history with dates, responses, and reasons for discontinuation |
| Non-formulary status | Request formulary exception with medical necessity justification |
| Lack of monitoring plan | Include differentiation syndrome monitoring protocol and lab schedule |
| Off-label prescriber | Ensure prescription comes from hematology/oncology specialist |
Appeals Process in Washington
If your prior authorization is denied, Washington residents have strong appeal rights under state law.
Internal Appeals (Humana)
- Deadline: 65 days from denial notice
- Timeline: 30 days for pre-service, 60 days for post-service decisions
- Expedited: 72 hours for urgent cases
- How to file: Humana appeals portal or written request
External Review (Independent Review Organization)
If Humana upholds the denial, your case automatically goes to an Independent Review Entity (IRE) for external review. In Washington, this process is particularly robust:
- Timeline: 30 days for medical services, 7 days for prescription drugs
- Cost: Free to you
- Binding: If the IRE overturns the denial, Humana must provide coverage
- Washington advantage: The state's strong consumer protection laws and network of medical experts often lead to favorable outcomes for complex cases
For additional support, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.
Medical Necessity Documentation
Your oncologist's medical necessity letter should include:
Clinical Requirements Checklist:
- AML diagnosis with pathology confirmation
- IDH1 mutation status (specific mutation variant)
- Disease status (relapsed vs. refractory)
- Prior treatment history with outcomes
- Contraindications to alternative therapies
- Performance status and comorbidities
- Monitoring plan for differentiation syndrome
- Treatment goals and expected outcomes
Supporting Evidence:
- FDA labeling for approved indication
- Peer-reviewed studies supporting efficacy
- Professional society guidelines (NCCN, ELN)
- Molecular testing reports
From Our Advocates: We've seen cases where initial denials were overturned simply by including a detailed timeline of prior therapies with specific dates and response assessments. Payers want to see that standard treatments have been tried and failed before approving expensive targeted therapies.
Cost Assistance and Support
Given Rezlidhia's high cost, explore these support options:
- Manufacturer assistance: Contact Rigel Pharmaceuticals for patient support programs
- Medicare Extra Help: Low-income subsidies for Part D costs
- State pharmacy assistance: Washington's Senior Prescription Drug Program
- Foundation grants: Organizations like CancerCare and Leukemia & Lymphoma Society
When navigating complex prior authorization requirements and appeals, consider working with specialists who understand payer policies. Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned to each payer's specific requirements.
FAQ
Q: How long does Humana prior authorization take for Rezlidhia? A: Humana commits to decisions within one business day for 95% of complete electronic submissions. Standard timeline is up to 72 hours.
Q: What if Rezlidhia is not on Humana's formulary? A: You can request a formulary exception. Your prescriber must provide written justification explaining why covered alternatives would be less effective or cause adverse effects.
Q: Can I get an expedited appeal if my health is at risk? A: Yes. Urgent appeals must be decided within 72 hours. Your oncologist should clearly document why delays would jeopardize your health.
Q: Does Washington state law provide extra protection for cancer drug appeals? A: Yes. Washington's external review process through Independent Review Organizations is particularly strong, with binding decisions that insurers must honor.
Q: What happens if I miss the 65-day appeal deadline? A: Late appeals may still be accepted by the Independent Review Entity, but standard timeframes don't apply. File as soon as possible with an explanation for the delay.
Q: Do I need to try other treatments first (step therapy)? A: Possibly. Many plans require trials of preferred therapies first. Your oncologist can request a step therapy exception if other treatments are contraindicated or have failed.
For additional support navigating these requirements, Counterforce Health specializes in creating comprehensive appeals packages that address payer-specific criteria and maximize approval chances.
Sources & Further Reading
- Humana Prior Authorization Portal
- Washington Insurance Commissioner Appeals Guide
- Humana Member Appeals Process
- Medicare Part D Exception Process
- FDA Rezlidhia Prescribing Information
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance plan for personalized guidance. For official Washington state insurance resources and assistance, visit insurance.wa.gov or call 1-800-562-6900.
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