By Counterforce Health Team in Sylvant (siltuximab) —

How to Get Sylvant (Siltuximab) Covered by Humana in Michigan: Complete PA Guide and Appeal Process

Quick Answer: Getting Sylvant (Siltuximab) Covered by Humana in Michigan

Humana requires prior authorization for Sylvant (siltuximab) in multicentric Castleman disease (MCD). To get approval: 1) Verify your diagnosis meets FDA criteria (HIV-negative, HHV-8-negative MCD), 2) Document failed prior therapies like rituximab, and 3) Submit PA through your provider using Humana's online portal with complete medical records. If denied, you have 65 days to appeal internally, then 127 days to request external review through Michigan DIFS. Start today: Ask your doctor to check Humana's coverage policies and gather your treatment history.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Sylvant Coverage
  4. Coding and Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in Michigan
  11. Costs and Financial Assistance
  12. FAQ

Who Should Use This Guide

This guide is for patients diagnosed with multicentric Castleman disease (MCD) who need Sylvant (siltuximab) covered by their Humana plan in Michigan. You'll also find this useful if you're a caregiver, provider, or advocate helping someone navigate the prior authorization process.

Expected outcome: Following this checklist increases your chances of first-time approval and helps you avoid common pitfalls that lead to denials. If you do get denied initially, you'll have the tools to file a successful appeal.

Member & Plan Basics

Verify Your Coverage Status

Before starting, confirm these basics:

  • Active Humana coverage: Log into MyHumana or call the number on your insurance card
  • Plan type: Sylvant requires prior authorization on most Humana Medicare Advantage plans
  • Deductible status: As a Part B drug, Sylvant may be subject to your medical (not pharmacy) deductible
  • Authorization requirements: Check if your plan requires prior authorization for specialty biologics
Note: Sylvant is typically covered under Medicare Part B (medical benefits) rather than Part D (pharmacy benefits) since it's administered by infusion.

Clinical Criteria for Sylvant Coverage

FDA-Approved Indication

Sylvant is FDA-approved specifically for HIV-negative and HHV-8-negative idiopathic multicentric Castleman disease (iMCD). Humana's coverage policy requires:

Requirement Documentation Needed
Confirmed MCD diagnosis Lymph node biopsy with pathology report
HIV-negative status Recent HIV test results (within 6 months)
HHV-8-negative status HHV-8 testing via immunohistochemistry or PCR
Adequate blood counts ANC ≥1.0 × 10⁹/L, platelets ≥75 × 10⁹/L initially

Step Therapy Requirements

Most Humana plans require you've tried and failed other treatments first, including:

  • Rituximab (375 mg/m² weekly × 4 cycles)
  • Corticosteroids (if not contraindicated)
  • Combination chemotherapy (such as R-CHOP, if appropriate)

Document the specific reasons each treatment failed (lack of efficacy, intolerance, contraindications).

Coding and Billing Requirements

Medical Coding

  • Primary diagnosis: D73.2 (Castleman disease)
  • HCPCS code: J2860 (Injection, siltuximab, 10 mg)
  • Typical dosing: 11 mg/kg IV every 3 weeks
  • Billing units: Each vial contains 100 mg; calculate units based on patient weight

Required Lab Values

Your provider must document baseline and monitoring labs:

  • Complete blood count with differential
  • Comprehensive metabolic panel
  • C-reactive protein (CRP)
  • Interleukin-6 levels (if available)

Documentation Packet Checklist

Provider Medical Necessity Letter Must Include:

✓ Patient demographics and insurance information
✓ ICD-10 diagnosis code D73.2 (Castleman disease)
✓ Clinical history including symptom severity and functional impact
✓ Biopsy results confirming MCD diagnosis
✓ HIV/HHV-8 test results (both negative)
✓ Prior treatment failures with specific dates, doses, and reasons for discontinuation
✓ Proposed dosing (11 mg/kg IV every 3 weeks)
✓ Treatment goals and expected outcomes
✓ Clinical guidelines supporting use (FDA approval, NCCN if applicable)

Supporting Documents:

  • Recent clinic notes (last 3 months)
  • Laboratory results
  • Pathology report from lymph node biopsy
  • Prior therapy documentation
  • Imaging studies showing lymphadenopathy

Counterforce Health helps providers create comprehensive, evidence-backed appeals that align with each payer's specific requirements. Their platform analyzes denial letters and plan policies to draft targeted rebuttals with the right clinical citations and procedural requirements.

Submission Process

Step-by-Step Submission

  1. Provider submits PA request via Humana's provider portal
  2. Include all required documentation from the checklist above
  3. Use correct form version (verify current forms on Humana's website)
  4. Submit to specialty pharmacy CenterWell Specialty Pharmacy handles Sylvant distribution

Timeline Expectations

  • Standard review: Up to 14 days
  • Expedited review: 72 hours (requires urgent medical necessity)
  • Peer-to-peer review: Available if initial request is denied

Specialty Pharmacy Requirements

Humana requires Sylvant be dispensed through CenterWell Specialty Pharmacy, their preferred specialty vendor nationwide.

Patient Registration Process:

  1. Prescription routing: Your provider sends the prescription directly to CenterWell
  2. Patient enrollment: Call 1-800-486-2668 to complete intake
  3. Insurance verification: CenterWell confirms PA approval and benefits
  4. Delivery coordination: Schedule infusion appointments with your provider
  5. Ongoing support: Access to pharmacist counseling and refill management

After Submission: What to Expect

Track Your Request

  • Confirmation number: Save the PA reference number from submission
  • Status checks: Call Humana or check online portal every 3-5 business days
  • Response timeline: Standard decisions within 14 days, expedited within 72 hours

What to Record

Keep detailed records of:

  • PA submission date and confirmation number
  • All phone calls with dates, times, and representative names
  • Any additional information requests
  • Decision letters (approval or denial)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing HIV/HHV-8 test results Submit recent negative test results with lab report headers
Insufficient prior therapy documentation Provide detailed treatment history with dates, doses, and failure reasons
Diagnosis not clearly documented Include pathology report excerpt highlighting MCD features
Not meeting blood count thresholds Submit recent CBC showing adequate counts or explain medical necessity despite low counts
Missing clinical notes Attach comprehensive provider notes detailing symptoms and functional impact

Appeals Process in Michigan

Internal Appeal (First Level)

If your initial PA is denied:

  • Timeline: 65 days from denial notice to file appeal
  • How to file: Submit through MyHumana portal or mail written appeal
  • Required documents: Denial letter, additional medical records, updated medical necessity letter
  • Decision timeframe: 30 days for standard, 72 hours for expedited

External Review (Second Level)

After internal appeal denial, Michigan residents can request external review:

  • Timeline: 127 days from final internal denial
  • Filing method: Michigan DIFS External Review Request form online or by mail
  • Cost: Free to patients
  • Decision timeframe: 60 days standard, 72 hours expedited
  • Binding decision: If approved, Humana must comply
Michigan-specific advantage: The 127-day deadline gives you more time than the federal 120-day standard, providing extra flexibility for gathering documentation.

When to Request Expedited Review

Request expedited appeals if:

  • Your health would be in serious jeopardy waiting for standard review
  • You're experiencing disease progression
  • Hospitalization is likely without treatment

Your doctor must provide a letter supporting the urgent need.

For help with the appeals process, contact Michigan DIFS at 877-999-6442.

Costs and Financial Assistance

Insurance Coverage

  • Medicare Part B: Typically covers 80% after deductible
  • Supplemental insurance: May cover remaining 20% copay
  • Medicare Advantage: Copay varies by plan (often $100-500 per infusion)

Financial Assistance Options

  • Janssen CarePath: Manufacturer copay assistance program
  • Patient Access Network Foundation: Grants for rare disease medications
  • CancerCare: Financial assistance for cancer-related treatments
  • State pharmaceutical assistance: Michigan may offer additional programs for eligible residents

FAQ

How long does Humana prior authorization take for Sylvant in Michigan? Standard PA decisions take up to 14 days. Expedited reviews (requiring urgent medical necessity documentation) are completed within 72 hours.

What if Sylvant is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate or have failed.

Can I get an expedited appeal in Michigan? Yes, both Humana internal appeals and Michigan DIFS external reviews offer expedited options (72 hours) when your doctor certifies that delays would harm your health.

Does step therapy apply if I tried treatments outside Michigan? Yes, prior therapy failures from any location count toward step therapy requirements, as long as you have proper documentation.

What happens if CenterWell Specialty Pharmacy denies my prescription? Contact Humana member services immediately. Specialty pharmacy denials are often due to PA status issues that can be resolved quickly.

How much will Sylvant cost with Humana coverage? Costs vary by plan type. Medicare Advantage members typically pay $100-500 per infusion after meeting deductibles. Contact your plan for specific copay information.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company for plan-specific requirements. Coverage policies and procedures may change; verify current information with official sources.

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