By Counterforce Health Team in Sylvant (siltuximab) —

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

Answer Box: Getting Sylvant (Siltuximab) Covered by Humana in Washington

Humana requires prior authorization for Sylvant (siltuximab) to treat HIV-negative, HHV-8-negative multicentric Castleman disease. Your provider submits the PA request via Humana's provider portal with documentation of failed prior therapies (rituximab, corticosteroids, or chemotherapy), HIV/HHV-8 test results, and lymph node biopsy. Standard decisions take 14 days; expedited reviews 72 hours. If denied, you have 65 days to appeal internally, then can request Washington's external review through an Independent Review Organization (IRO) within 60 days of final denial.

First step today: Contact your prescribing physician to initiate the PA request and gather required documentation.

Table of Contents

Start Here: Verify Your Plan and Coverage

Before beginning the prior authorization process, confirm your specific Humana plan type. Sylvant (siltuximab) is typically covered under Medicare Part B (medical benefits) rather than Part D (pharmacy), as it's a professionally administered infusion therapy.

Check your plan documents or call the member services number on your insurance card to verify:

  • Whether Sylvant requires prior authorization on your specific plan
  • Your current formulary tier placement
  • Any step therapy requirements
  • Your estimated out-of-pocket costs after approval
Tip: Most Humana Medicare Advantage plans cover 80% of Part B drugs after your medical deductible, with copays typically ranging from $100-500 per infusion.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Diagnosis HIV-negative, HHV-8-negative multicentric Castleman disease Lymph node biopsy pathology report (ICD-10: D73.2) Humana PA Guidelines
HIV Testing Negative HIV status Lab results within 6 months FDA Label Requirements
HHV-8 Testing Negative HHV-8 status Immunohistochemistry or PCR test results FDA Label Requirements
Step Therapy Failed prior treatments Documentation of rituximab, corticosteroids, or chemotherapy failures Humana Step Therapy List
Lab Values Adequate blood counts ANC ≥1.0 × 10⁹/L, platelets ≥75 × 10⁹/L Clinical requirement

Medical Necessity Documentation

Your prescribing physician must provide a comprehensive letter including:

  1. Confirmed diagnosis with pathology report showing multicentric Castleman disease
  2. HIV and HHV-8 negative status with recent test results
  3. Prior treatment failures with specific details:
    • Rituximab (375 mg/m² weekly × 4 cycles) - dates, response, reason for discontinuation
    • Corticosteroids (if not contraindicated) - doses tried, duration, outcomes
    • Combination chemotherapy (R-CHOP or similar) - cycles completed, efficacy
  4. Current clinical status and symptoms requiring treatment
  5. Dosing plan: 11 mg/kg IV every 3 weeks (HCPCS code J2860)

Forms and Submission Process

Provider Submission (Primary Method)

Your healthcare provider submits the prior authorization through:

  • Online: Humana Provider Portal
  • Fax: 1-888-447-xxxx (verify current number with provider portal)
  • Phone: Provider services line for urgent cases

Required Forms

  • Prior Authorization Request Form (accessed through provider portal)
  • Medical necessity letter from prescribing physician
  • Supporting clinical documentation (biopsy results, lab values, treatment history)

Timeline Expectations

Request Type Decision Timeframe What Happens Next
Standard PA Up to 14 days Written notification of decision
Expedited PA 72 hours Requires documentation of urgent medical need
Peer-to-Peer 1-2 business days If initial PA denied, provider can request clinical discussion

Specialty Pharmacy Requirements

Once your prior authorization is approved, Humana requires you to use CenterWell Specialty Pharmacy for Sylvant dispensing and coordination.

Enrollment Steps

  1. Call CenterWell: 1-800-486-2668 to complete patient intake
  2. Provide information: Insurance details, prescriber contact, preferred infusion site
  3. Schedule delivery: Coordinate with your infusion center for timing
  4. Set up refills: Establish ongoing delivery schedule (every 3 weeks)
Note: CenterWell will handle insurance billing and coordinate directly with your infusion center for delivery timing.

Appeals Process for Humana in Washington

If your initial prior authorization is denied, you have multiple appeal options with specific timelines.

Internal Appeals Timeline

Appeal Level Filing Deadline Humana Decision Time How to Submit
First Appeal 65 days from denial notice 7 calendar days (standard) Humana Member Portal or mail
Expedited Appeal 65 days from denial notice 72 hours Phone + written follow-up

Required Documentation for Appeals

  • Original denial letter from Humana
  • Updated medical records showing continued medical necessity
  • Additional clinical evidence (new test results, specialist opinions)
  • Prescriber attestation confirming ongoing need for Sylvant

Submission Methods

  • Mail: Humana Grievances and Appeals, P.O. Box 14546, Lexington, KY 40512-4546
  • Online: Through your MyHumana member account
  • Phone: Call the number on your denial notice for expedited requests

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps patients and providers navigate complex prior authorization requirements and appeal processes for specialty medications like Sylvant.

Washington State External Review

If Humana upholds their denial after internal appeals, Washington residents can request an Independent Review Organization (IRO) external review through the Office of the Insurance Commissioner.

External Review Process

Washington's external review process is governed by RCW 48.43.535 and provides an independent assessment of medical necessity denials.

Key Steps:

  1. File within 60 days of Humana's final internal denial
  2. Submit written request to Humana (they forward to OIC)
  3. IRO assignment - Washington OIC assigns certified independent reviewers
  4. Submit additional evidence within 5 business days to the IRO
  5. IRO decision - binding determination within 20 days (standard) or 72 hours (expedited)

When to Request Expedited External Review

Request expedited review if:

  • Your health could be seriously jeopardized by delay
  • You're receiving ongoing emergency services
  • Continued hospital stay or admission is involved

Washington OIC Support

Phone: 800-562-6900 or 360-586-0241 (TDD) Website: insurance.wa.gov complaint portal Services: Consumer advocacy, appeal assistance, template letters

From our advocates: "We've seen Washington's external review process successfully overturn Humana denials for rare disease medications when the clinical evidence clearly supports medical necessity. The key is submitting comprehensive documentation that addresses the specific denial reasons while demonstrating the treatment meets accepted medical standards."

Support Lines and Contacts

Humana Member Services

  • General inquiries: Number on your member ID card
  • Prior authorization status: Provider portal or member services
  • Appeals assistance: 800-867-6601 for expedited requests

Washington State Resources

  • Office of Insurance Commissioner: 800-562-6900
  • Consumer advocacy: Available for appeal guidance and complaint filing
  • External review requests: Submit through OIC or directly to your insurer

Manufacturer Support

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Missing HIV/HHV-8 testing Submit current lab results HIV test within 6 months, HHV-8 immunohistochemistry or PCR
Insufficient step therapy Document all prior failures Detailed treatment history with dates, doses, outcomes, intolerances
Non-formulary status File formulary exception Medical necessity letter explaining why formulary alternatives are inadequate
Experimental/investigational Provide FDA approval evidence FDA label, clinical guidelines, peer-reviewed studies supporting use

When working with Counterforce Health, their platform automatically identifies these common denial patterns and generates targeted responses that address each specific criterion in your plan's policy.

FAQ

How long does Humana prior authorization take for Sylvant in Washington? Standard prior authorization decisions take up to 14 days. Expedited requests (requiring documentation of urgent medical need) are decided within 72 hours.

What if Sylvant is not on my Humana formulary? You can request a formulary exception through the same prior authorization process. Your provider must demonstrate that formulary alternatives are less effective or cause adverse effects for your specific condition.

Can I request an expedited appeal if Humana denies coverage? Yes, if you can document that delay in treatment could seriously jeopardize your health. Expedited appeals must be decided within 72 hours.

Does Washington's external review apply to Medicare Advantage plans? Washington's external review process applies to fully-insured plans. For Medicare Advantage, federal Medicare appeals processes may take precedence, but the Washington Office of Insurance Commissioner can provide guidance on your specific situation.

What happens if the IRO overturns Humana's denial? The IRO decision is binding on Humana. They must provide coverage and pay for the treatment as determined by the independent reviewers.

How much will Sylvant cost with Humana coverage? Most Humana Medicare Advantage plans cover 80% of Part B drugs after your medical deductible. Your copay typically ranges from $100-500 per infusion, depending on your specific plan's cost-sharing structure.

Update Cadence

Check quarterly for updates to:

  • Humana formulary changes (typically January 1st annually)
  • Prior authorization requirements and forms
  • Washington state appeal processes and contact information
  • Manufacturer patient support programs

Monitor annually for:

  • New clinical guidelines that may support coverage
  • Changes to Medicare Part B coverage policies
  • Updates to Washington insurance regulations

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by plan and can change. Always verify current requirements with Humana directly and consult with your healthcare provider for medical decisions. For personalized assistance with complex prior authorization and appeal processes, consider consulting with coverage advocacy services like Counterforce Health.

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