By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Humana in Washington: Appeals Guide & Forms

Answer Box: Getting Taltz (Ixekizumab) Covered by Humana in Washington

Quick Path to Approval: Humana Medicare Advantage plans may cover Taltz for psoriasis, psoriatic arthritis, and ankylosing spondylitis, but prior authorization is typically required. First step today: Check your specific plan's formulary at MyHumana and gather documentation of failed TNF inhibitor trials. If denied, you have 65 days to appeal internally, then can request external review through Washington's Independent Review Organization (IRO) within 60 days. Call the Washington Office of Insurance Commissioner at 1-800-562-6900 for free guidance.

Table of Contents

  1. Read Your Denial Letter
  2. Common Fixable Issues
  3. Coverage Requirements at a Glance
  4. Step-by-Step: Fastest Path to Approval
  5. First-Level Appeal Strategy
  6. Peer-to-Peer Review Process
  7. Washington External Review Process
  8. Appeal Templates & Scripts
  9. Medical Necessity Documentation
  10. When to Escalate
  11. Cost-Saving Options
  12. FAQ

Read Your Denial Letter

Your Humana denial letter contains critical information that determines your next steps. Look for these key elements:

Denial Reason Codes:

  • Prior Authorization Required: Taltz needs pre-approval before coverage
  • Step Therapy Not Met: Must try preferred medications first (typically TNF inhibitors)
  • Non-Formulary: Taltz isn't on your plan's covered drug list
  • Quantity Limits: Dosing exceeds plan allowances
  • Medical Necessity: Insufficient clinical documentation

Critical Deadlines:

  • Internal Appeal: 65 days from denial date for Medicare Part D
  • External Review: 60 days from final internal denial in Washington
  • Expedited Appeals: Available for urgent medical situations
Note: Keep your original denial letter and all correspondence. You'll need specific reference numbers for appeals.

Common Fixable Issues

Many Taltz denials can be resolved without formal appeals:

Missing Documentation:

  • Prior TNF inhibitor trial records
  • Disease severity measurements (BSA, PASI scores)
  • Tuberculosis screening results
  • Specialist consultation notes

Coding Problems:

  • Incorrect diagnosis codes (ICD-10)
  • Wrong drug codes or dosing information
  • Missing modifier codes for administration

Benefit vs. Medical Policy Issues:

  • Drug submitted under wrong benefit (Part B vs. Part D)
  • Site of care restrictions not addressed
  • Age or indication mismatches

Contact your prescriber's office to verify all information matches Humana's requirements before filing an appeal.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Pre-approval required Complete PA form with clinical notes Humana PA Process
Step Therapy Try preferred drugs first TNF inhibitor failure documentation Humana Step Therapy
Medical Necessity Clinical justification required Disease severity, prior treatments Taltz Medical Necessity
Formulary Status Must be on drug list Check plan formulary MyHumana Drug List
Quantity Limits Dosing restrictions may apply Prescriber justification if exceeded Verify with current plan

Step-by-Step: Fastest Path to Approval

1. Verify Formulary Status

Who: Patient
Action: Log into MyHumana and search for Taltz (ixekizumab)
Timeline: 5 minutes
Link: Humana Drug Search

2. Gather Required Documentation

Who: Patient + Clinic
Action: Collect TNF inhibitor trial records, lab results, clinical notes
Timeline: 1-3 days
Key Documents: Disease severity scores, prior therapy failures, TB screening

3. Submit Prior Authorization

Who: Prescriber
Action: Complete Humana PA form with all supporting documents
Timeline: 7 days for standard review
Portal: Humana provider portal or fax submission

4. Request Expedited Review (If Urgent)

Who: Prescriber
Action: Document urgent medical need in PA request
Timeline: 72 hours for expedited decisions
Criteria: Serious health jeopardy without treatment

5. Schedule Peer-to-Peer (If Denied)

Who: Prescriber
Action: Request direct discussion with Humana medical director
Timeline: Within 24-48 hours of request
Preparation: Clinical guidelines, patient-specific factors ready

6. File Internal Appeal

Who: Patient or prescriber
Action: Submit appeal form with additional evidence
Timeline: 65 days to file, 7 days for decision
Form: Humana Appeal Forms

7. Request External Review

Who: Patient
Action: File with Washington IRO if internal appeal fails
Timeline: 60 days to file, 20 days for decision
Contact: Washington Insurance Commissioner

First-Level Appeal Strategy

Your internal appeal should address the specific denial reason with targeted evidence:

For Step Therapy Denials:

  • Document TNF inhibitor trials with specific medications, dates, and outcomes
  • Include adverse event reports or contraindications
  • Provide specialist letters explaining medical necessity for Taltz specifically

For Medical Necessity Denials:

  • Submit updated disease activity scores (PASI, BSA measurements)
  • Include functional impact documentation
  • Attach relevant clinical guidelines supporting Taltz use

For Non-Formulary Denials:

  • Request formulary exception with comparative effectiveness data
  • Document contraindications to formulary alternatives
  • Include cost-effectiveness analysis if available
Clinician Corner: Medical necessity letters should follow the SOAP format with specific emphasis on failed prior treatments, current disease severity, and expected outcomes with Taltz therapy.

Peer-to-Peer Review Process

Peer-to-peer reviews allow your prescriber to discuss your case directly with Humana's medical director:

Scheduling Process:

  1. Contact Humana provider services to request peer-to-peer
  2. Provide case details and preferred call times
  3. Receive confirmation with scheduled call time

Preparation Checklist:

  • Patient's complete medical history
  • Specific TNF inhibitor trials and outcomes
  • Current disease severity documentation
  • Clinical guidelines supporting Taltz use
  • Patient-specific contraindications to alternatives

Key Talking Points:

  • Disease impact on quality of life
  • Previous treatment failures with specific details
  • Medical rationale for IL-17A inhibition
  • Expected treatment outcomes and monitoring plan

Washington External Review Process

If Humana's internal appeal is unsuccessful, Washington residents can request an independent external review:

Eligibility Requirements:

  • Completed all internal appeal levels
  • Request filed within 60 days of final internal denial
  • Dispute involves medical necessity or appropriateness of care

Filing Process:

  1. Submit request to Washington Office of Insurance Commissioner
  2. Include all denial letters and medical records
  3. Pay any required filing fees (often waived for urgent cases)

Timeline:

  • Standard Review: 20 days for fully-insured plans
  • Expedited Review: 72 hours for urgent medical situations
  • Written Decision: Provided within specified timeframe

Contact Information:

The IRO decision is binding on Humana if they rule in your favor.

Appeal Templates & Scripts

Patient Phone Script for Humana

"Hello, I'm calling about a prior authorization denial for Taltz, reference number [X]. I'd like to understand the specific denial reason and request information about the appeals process. Can you also tell me if a peer-to-peer review is available for my prescriber?"

Medical Necessity Letter Template

RE: [Patient Name], DOB: [Date], Policy #: [Number]
Request for Coverage of Taltz (ixekizumab)

CLINICAL BACKGROUND:
[Patient] is a [age]-year-old with moderate-to-severe plaque psoriasis diagnosed [date]. Current BSA involvement is [X]% with PASI score of [X].

PRIOR TREATMENTS AND OUTCOMES:
1. TNF Inhibitor #1: [Drug name, dates, outcome, reason for discontinuation]
2. TNF Inhibitor #2: [Drug name, dates, outcome, reason for discontinuation]
3. Other therapies: [Methotrexate, phototherapy, etc.]

MEDICAL NECESSITY RATIONALE:
Based on [clinical guidelines], IL-17A inhibition with Taltz is medically necessary due to:
- Inadequate response to TNF inhibitors
- [Specific contraindications to alternatives]
- Expected improvement in disease activity and quality of life

SUPPORTING EVIDENCE:
- FDA labeling for moderate-to-severe psoriasis
- [Relevant clinical studies or guidelines]
- Patient-specific factors supporting Taltz selection

Medical Necessity Documentation

Humana requires specific clinical documentation to establish medical necessity for Taltz:

For Psoriasis:

  • Body Surface Area (BSA) ≥3% or <3% with high-impact areas affected
  • PASI score or physician global assessment
  • Documentation of TNF inhibitor trials (≥3 months each)
  • Contraindications or adverse events with preferred therapies

For Psoriatic Arthritis:

  • Confirmed diagnosis by rheumatologist
  • Active joint involvement with imaging or clinical findings
  • Failed conventional synthetic DMARDs
  • TNF inhibitor trial documentation

For Ankylosing Spondylitis:

  • Objective signs of inflammation (CRP elevation or MRI sacroiliitis)
  • Failed NSAID trials (2 medications, ≥3 months each)
  • TNF inhibitor failure documentation
  • Rheumatologist consultation required

Laboratory Requirements:

  • Tuberculosis screening (within 12 months)
  • Hepatitis B and C screening
  • Complete blood count
  • Liver function tests

When to Escalate

Consider escalating to Washington state regulators when:

Humana Issues:

  • Unreasonable delays in processing appeals
  • Failure to follow Medicare or state appeal procedures
  • Denial of expedited reviews for urgent situations
  • Inadequate peer-to-peer review process

Escalation Steps:

  1. Document all interactions with Humana (dates, names, outcomes)
  2. File complaint with Washington Insurance Commissioner
  3. Contact Medicare if Part D or Medicare Advantage issues
  4. Consider legal consultation for complex cases

Washington Insurance Commissioner:

Cost-Saving Options

While pursuing coverage, explore these cost-reduction strategies:

Manufacturer Support:

Foundation Assistance:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Chronic Disease Fund

State Programs:

  • Washington State Prescription Drug Assistance Programs
  • Apple Health (Medicaid) coverage if eligible

Counterforce Health helps patients navigate the complex prior authorization and appeals process for specialty medications like Taltz. Our platform analyzes denial letters, identifies specific appeal strategies, and provides evidence-backed documentation to improve approval rates. By turning insurance denials into targeted appeals aligned with each payer's specific requirements, we help patients get the treatments they need while reducing administrative burden on healthcare providers.

FAQ

How long does Humana prior authorization take for Taltz in Washington? Standard prior authorization decisions are made within 7 calendar days for Medicare Part D. Expedited reviews are completed within 72 hours for urgent medical situations.

What if Taltz is not on my Humana formulary? You can request a formulary exception by demonstrating medical necessity and contraindications to formulary alternatives. Include comparative effectiveness data and specialist support letters.

Can I request an expedited appeal if my condition is worsening? Yes, expedited appeals are available when standard timelines could seriously jeopardize your health. Your prescriber must document the urgent medical need.

Does Washington's step therapy requirement apply if I tried TNF inhibitors in another state? Yes, documented TNF inhibitor failures from other states count toward Washington step therapy requirements. Ensure all medical records are transferred to your current prescriber.

What happens if both internal and external appeals fail? You may have additional options including Medicare appeals (for Medicare Advantage), legal consultation, or exploring alternative treatment pathways with your prescriber.

How much does Taltz cost without insurance coverage? The list price is approximately $7,261.51 per pen. However, manufacturer patient assistance programs and foundation grants may significantly reduce out-of-pocket costs.

Can family members help with the appeals process? Yes, you can designate a representative to file appeals on your behalf. Complete Humana's representative designation form to authorize family member involvement.

What documentation should I keep during the appeals process? Maintain copies of all denial letters, appeal submissions, correspondence with Humana, medical records, and receipts. Create a timeline of all interactions for reference.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For personalized assistance with insurance appeals and prior authorization, consider working with specialized advocacy services like Counterforce Health, which helps patients navigate complex coverage requirements and improve approval rates for specialty medications.

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