By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Humana in Michigan: Complete Prior Authorization Guide

Quick Answer: Getting Taltz Covered by Humana in Michigan

Yes, Taltz (ixekizumab) is covered by Humana but requires prior authorization and step therapy completion. Fastest path: Have your dermatologist submit electronic PA through Humana's provider portal with documented TNF inhibitor failures (3+ months each), tuberculosis screening, and current PASI scores. Start today: Call your clinic to request prior therapy records and schedule TB screening if not current. If denied, you have 65 days to appeal internally, then 127 days for Michigan's external review through DIFS.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Step Therapy Requirements
  4. Required Documentation
  5. Specialty Pharmacy Requirements
  6. Common Denial Reasons & Solutions
  7. Appeals Process in Michigan
  8. Costs and Financial Assistance
  9. When to Escalate
  10. FAQ

Coverage Basics

Is Taltz Covered by Humana?

Taltz is included on Humana's Medicare Advantage formularies as a specialty tier medication with 25-33% coinsurance rather than a flat copay. This means your out-of-pocket costs depend on the drug's negotiated price.

Which Humana Plans Cover Taltz?

Most Humana Medicare Advantage and Part D plans in Michigan cover Taltz for FDA-approved indications:

  • Moderate-to-severe plaque psoriasis (adults and pediatric ≥6 years)
  • Active psoriatic arthritis
  • Ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis
Note: Coverage varies by specific plan. Verify your plan's formulary at Humana.com/MedicareDrugList.

Prior Authorization Process

Who Submits the Request?

Your prescribing physician or their clinical staff must submit the prior authorization request—patients cannot submit directly for specialty medications like Taltz.

Submission Methods and Timelines

Method Timeline Best For
Electronic (Humana provider portal) 85% decided within 1 business day Standard requests
Fax submission Up to 7 calendar days When portal unavailable
Expedited request Within 72 hours Medical urgency

Phone support: Providers can call Humana Clinical Pharmacy at 866-461-7273 for urgent cases or submission assistance.

Step Therapy Requirements

TNF Inhibitor Trials Required

Humana requires documented failure of TNF inhibitors for at least 3 months each before approving Taltz. Acceptable TNF inhibitors include:

  • Humira (adalimumab)
  • Enbrel (etanercept)
  • Remicade (infliximab)
  • Simponi (golimumab)
  • Cimzia (certolizumab)

What Counts as "Failure"?

Documentation must show:

  • Inadequate clinical response after 3+ months
  • Intolerable side effects
  • Medical contraindications
  • Loss of efficacy over time
Tip: Previous insurance claims history may satisfy step therapy requirements if properly documented in your medical record.

Required Documentation

Medical Necessity Checklist

Your dermatologist or rheumatologist must provide:

Diagnosis Documentation:

  • ICD-10 codes for psoriasis (L40.x) or psoriatic arthritis (L40.5x)
  • Body Surface Area (BSA) involvement ≥3% or <3% with high-impact areas
  • PASI score or Physician Global Assessment

Safety Screening:

  • Tuberculosis screening within 12 months
  • Hepatitis B and C screening
  • Complete blood count and liver function tests

Treatment History:

  • Detailed records of prior TNF inhibitor trials
  • Dates, dosages, and reasons for discontinuation
  • Current disease severity assessment

Required Laboratory Tests

Before starting Taltz, patients must complete tuberculosis screening and age-appropriate vaccinations. Live vaccines are contraindicated during treatment.

Specialty Pharmacy Requirements

CenterWell Specialty Pharmacy

Taltz must be dispensed through Humana's preferred specialty pharmacy network, specifically CenterWell Specialty Pharmacy. Contact them at:

Phone: 844-486-2668 (TTY: 711)
Hours: Monday–Friday, 8 a.m.–8 p.m.; Saturday, 8 a.m.–6 p.m. (Central time)

Home Delivery Process

After prior authorization approval:

  1. CenterWell contacts you within 24-48 hours
  2. Coordinates delivery with temperature monitoring
  3. Provides injection training and patient education
  4. Manages manufacturer support program enrollment

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Documentation
Insufficient step therapy Submit detailed TNF inhibitor trial records Pharmacy claims + clinical notes showing 3+ month trials
Missing TB screening Complete tuberculosis evaluation Chest X-ray, tuberculin skin test, or interferon-gamma release assay
Inadequate diagnosis documentation Provide severity assessment PASI score, BSA measurement, or PGA documentation
Concurrent immunomodulator use Discontinue conflicting medications Updated medication list showing no overlapping biologics
Off-label indication Switch to FDA-approved indication or provide evidence Clinical guidelines supporting off-label use

Appeals Process in Michigan

Internal Appeal (Level 1)

Timeline: 65 days from denial date to file; 7 days for Humana's decision

How to Submit:

Michigan External Review

If Humana denies your internal appeal, you have 127 days to request external review through Michigan's Department of Insurance and Financial Services (DIFS).

Contact DIFS:

Expedited Appeals

Request expedited review if:

  • Delay would seriously jeopardize your health
  • Standard timeline could worsen your condition
  • You need urgent treatment initiation

Required: Physician letter stating medical urgency and potential harm from delay.

From our advocates: We've seen Michigan external reviews succeed when patients include a clear timeline showing disease progression during insurance delays, along with their dermatologist's letter explaining why Taltz is specifically needed over alternatives. The key is demonstrating medical necessity within your plan's own criteria.

Costs and Financial Assistance

Humana Coverage Structure

  • Tier: Specialty tier with 25-33% coinsurance
  • Supply limit: 30-day maximum per fill
  • Annual deductible: May apply depending on your specific plan

Manufacturer Support

Eli Lilly offers the Taltz Savings Card for eligible patients, potentially reducing copays to $5 per month. Eligibility restrictions apply for government insurance.

Additional Resources

  • Lilly Cares Foundation: Patient assistance for qualifying low-income patients
  • Michigan Medicaid: May provide coverage through Healthy Michigan plans
  • CancerCare Co-Payment Assistance: For psoriatic arthritis patients

Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-backed appeals tailored to each insurer's specific criteria. Their platform can identify the exact documentation needed to overturn Humana denials and streamline the appeal process.

When to Escalate

Contact Michigan DIFS

File a complaint with Michigan's insurance regulator if:

  • Humana exceeds response timelines
  • You suspect improper denial practices
  • External review is needed

Michigan DIFS Consumer Assistance:

Required Documentation for Complaints

  • Insurance policy information
  • Denial letters and correspondence
  • Medical records supporting necessity
  • Timeline of events and communications

FAQ

How long does Humana prior authorization take in Michigan? Electronic submissions through Humana's provider portal are decided within 1 business day for 85% of requests. Fax submissions take up to 7 calendar days. Expedited requests are processed within 72 hours.

What if Taltz is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity and contraindications to formulary alternatives. Your doctor can also request a peer-to-peer discussion with a Humana medical director.

Can I request an expedited appeal in Michigan? Yes, both Humana and Michigan DIFS offer expedited appeals when delays would seriously jeopardize your health. Requires a physician letter documenting medical urgency.

Does step therapy apply if I failed TNF inhibitors outside Michigan? Yes, documented failures from any location count toward step therapy requirements if properly recorded in your medical history and pharmacy claims.

What happens if I use an out-of-network pharmacy? Taltz must be filled at Humana network pharmacies to receive coverage. Using out-of-network pharmacies results in full out-of-pocket costs, which can exceed $5,000 per month.

How often do I need reauthorization? Initial authorizations are typically granted for 12 months. Reauthorization requires documentation of positive clinical response and continued medical necessity.

If you're struggling with Humana's prior authorization requirements, Counterforce Health can analyze your specific situation and help build a compelling case for coverage approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Humana plan and consult your healthcare provider for medical decisions. For official Michigan insurance appeals guidance, contact DIFS at 877-999-6442.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.