By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by Humana in New York: Prior Authorization Guide and Appeals Process

Answer Box: Getting Tagrisso Covered by Humana in New York

Tagrisso (osimertinib) requires prior authorization from Humana before coverage. To get approved: (1) Your doctor submits a PA request with EGFR mutation testing results and clinical documentation through Humana's provider portal, (2) Humana reviews within 7-30 days, and (3) If denied, you can appeal internally then file an external appeal with New York's Department of Financial Services within 4 months. Start by calling Humana at the number on your member card to confirm your plan's specific requirements.

Table of Contents

Understanding Tagrisso Coverage Requirements

Tagrisso (osimertinib) is a third-generation EGFR tyrosine kinase inhibitor used to treat EGFR-mutant non-small cell lung cancer (NSCLC). The medication typically costs over $15,000 per month, making insurance coverage essential for most patients.

Humana requires prior authorization for Tagrisso before the medication can be covered. This process involves your healthcare provider submitting clinical documentation to demonstrate medical necessity based on your specific diagnosis and treatment history.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before prescribing Humana PA Lists
EGFR Mutation Testing Must show positive EGFR mutation Lab results from tissue or liquid biopsy
Medical Necessity Must meet FDA-approved indications FDA Tagrisso Label
Renewal Timeline Reauthorization every 6-12 months Submit 30-45 days before expiration

Prior Authorization: The Fastest Path to Approval

Step 1: Confirm Your Coverage (Patient Action)

Call the member services number on your Humana card to verify:

  • Whether Tagrisso requires PA under your specific plan
  • Your plan's formulary tier for Tagrisso
  • Any quantity limits or step therapy requirements

Step 2: Gather Required Documentation (Clinic Action)

Your healthcare provider will need to compile:

Step 3: Submit Prior Authorization Request (Clinic Action)

Your provider can submit the PA request through:

Step 4: Track Your Request (Patient Action)

  • Standard PA decisions: 7-30 days
  • Expedited requests (urgent medical need): 72 hours
  • You'll receive a determination letter by mail
Tip: Request expedited review if you have urgent medical need or are experiencing disease progression.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
No EGFR mutation documented Submit comprehensive NGS testing results showing specific EGFR mutations (exon 19 deletions or L858R)
Wrong treatment setting Provide clinical documentation showing metastatic disease or adjuvant setting post-resection
Insufficient prior therapy Document previous treatments tried and reasons for failure/intolerance
Quantity limits exceeded Request exception with clinical justification for higher dosing

Appeals Process in New York

If your initial PA request is denied, New York offers robust appeal rights through multiple pathways.

Internal Appeal (First Step)

Contact Humana within 60 days of denial to request an internal appeal. Your healthcare provider should submit:

  • Updated clinical documentation
  • Peer-reviewed literature supporting Tagrisso use
  • Letter addressing specific denial reasons

External Appeal Through New York DFS

If your internal appeal is denied, you can file an external appeal with the New York Department of Financial Services within 4 months of the final adverse determination.

Timeline for External Appeals:

  • Standard appeals: 72 hours for non-formulary drugs
  • Expedited appeals: 24 hours for urgent drug denials

Required Forms:

Note: The external appeal agent's decision is binding on Humana. If approved, they must cover Tagrisso while you're taking it.

Getting Help with Appeals

Community Health Advocates provides free assistance to New York residents with insurance appeals. Call their helpline at 888-614-5400 (Monday-Friday, 9am-4pm) for guidance on:

  • Filing appeals and gathering documentation
  • Understanding your rights under New York law
  • Connecting with additional resources

Cost-Saving Programs

Even with insurance coverage, Tagrisso can involve significant out-of-pocket costs. Consider these assistance programs:

AstraZeneca Patient Assistance:

Foundation Support:

  • Patient Advocate Foundation
  • CancerCare Copay Assistance Foundation
  • Leukemia & Lymphoma Society copay assistance

Medicare Extra Help: If you have Medicare, you may qualify for Extra Help (Low Income Subsidy) to reduce prescription drug costs.

When to Get Help

Contact these resources if you're struggling with coverage:

For Coverage Issues:

For Treatment Questions:

From our advocates: "We've seen many Tagrisso approvals succeed when the provider submits comprehensive EGFR testing results upfront and clearly documents the specific mutation type. Taking time to address potential denial reasons in the initial request often prevents the need for appeals altogether."

Clinician Corner: Medical Necessity Documentation

Healthcare providers should include these elements in PA requests:

Essential Documentation:

  • Confirmed NSCLC diagnosis with staging
  • EGFR mutation testing results (specify mutation type: exon 19 deletion, L858R, or T790M)
  • Treatment setting (first-line metastatic, adjuvant post-resection, or post-progression)
  • Prior therapies attempted and outcomes
  • Clinical rationale for Tagrisso selection

Supporting Literature: Reference current treatment guidelines such as:

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies navigate complex prior authorization processes for oncology medications. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific payer requirements. By combining clinical documentation with the right regulatory citations, Counterforce Health helps streamline the approval process for life-saving cancer treatments like Tagrisso.

FAQ

How long does Humana prior authorization take for Tagrisso in New York? Standard PA decisions take 7-30 days, while expedited requests for urgent medical needs are processed within 72 hours.

What if Tagrisso is not on Humana's formulary? You can request a formulary exception with supporting clinical documentation. If denied, you can appeal through New York's external review process.

Can I get an expedited appeal in New York? Yes, New York allows expedited external appeals for urgent drug denials, with decisions issued within 24 hours if your health is at serious risk.

What EGFR mutations qualify for Tagrisso coverage? Coverage typically requires documented EGFR exon 19 deletions, L858R mutations, or T790M resistance mutations, depending on the treatment setting.

Does Humana require step therapy for Tagrisso? Requirements vary by plan. Some may require trying other EGFR inhibitors first, while others approve Tagrisso as first-line therapy for appropriate mutations.

How much will I pay out-of-pocket? Costs depend on your specific Humana plan's formulary tier, deductible, and copay structure. Contact member services for your exact costs.

Can I appeal if I live in New York but have coverage from another state? New York's external appeal rights apply to New York residents regardless of where their insurance plan is based.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For official guidance on New York insurance appeals, visit the New York State Department of Financial Services.

The approval process for specialty cancer medications involves complex medical and insurance considerations that Counterforce Health helps navigate through their evidence-based appeal platform, but individual outcomes may vary based on specific clinical circumstances and plan requirements.

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