By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Humana in Florida: Prior Authorization, Appeals, and Cost Assistance

Quick Answer: Getting Tysabri (Natalizumab) Covered by Humana in Florida

Humana Medicare requires prior authorization and TOUCH program enrollment for Tysabri (natalizumab) coverage. If denied, you have 65 days to appeal with medical necessity documentation. First step: Have your doctor submit a PA request with complete TOUCH enrollment forms and clinical evidence showing why formulary alternatives won't work. For urgent cases, request expedited review through Humana's member portal.

Fastest path to approval:

  1. Ensure TOUCH program enrollment is complete
  2. Submit comprehensive prior authorization with medical necessity letter
  3. Include documentation of failed alternative treatments

Table of Contents

What Drives Tysabri Coverage Costs

Tysabri (natalizumab) is classified as a specialty tier medication under most Humana Medicare plans, typically placed in Tier 4 or Tier 5. This high-cost classification means you'll face coinsurance rather than a flat copay—often around 33% of the drug's cost.

Several factors influence your out-of-pocket expenses:

  • Formulary tier placement: Specialty drugs carry the highest cost-sharing
  • Site of administration: Costs vary between hospital outpatient, infusion centers, and physician offices
  • Prior authorization requirements: Delays can affect treatment timing and costs
  • REMS program compliance: The TOUCH program adds administrative requirements
Note: Tysabri is administered as an IV infusion every 4 weeks, typically billed under Medicare Part B rather than Part D, which affects your coverage structure and cost-sharing.

Investigating Your Humana Benefits

Before starting treatment, gather this essential information from your Humana plan:

Questions to ask Humana Customer Service (1-800-HUMANA):

  • Is Tysabri on my plan's formulary, and what tier?
  • What's my coinsurance percentage for specialty tier drugs?
  • Which specialty pharmacies are in-network for Tysabri?
  • What prior authorization documentation is required?
  • Are there quantity limits or step therapy requirements?

Information to record:

  • Your specific plan name and member ID
  • Deductible amounts and whether you've met them
  • Maximum out-of-pocket limits for 2025
  • Appeals deadlines and submission methods

Contact your plan directly using the phone number on your member ID card, as formularies can vary by region and plan type.

Prior Authorization Requirements

Humana requires comprehensive documentation for Tysabri approval, centered around the FDA's TOUCH program requirements:

TOUCH Program Enrollment

Required for all patients:

  • Patient enrollment in TOUCH with signed consent forms
  • Prescriber registration and certification in TOUCH
  • Pharmacy/infusion center TOUCH enrollment
  • Ongoing compliance with safety monitoring protocols

Medical Necessity Documentation

Your physician must provide:

Clinical Evidence:

  • Confirmed diagnosis (relapsing MS or Crohn's disease with ICD-10 codes)
  • Documentation of prior treatment failures or intolerances
  • Contraindications to formulary alternatives
  • JCV antibody status and PML risk assessment
  • Recent MRI results showing disease activity

Treatment History:

  • List of previously tried disease-modifying therapies
  • Reasons for discontinuation (lack of efficacy, side effects, contraindications)
  • Duration of each prior treatment
  • Clinical response measurements

Submit requests through Humana's provider portal or via the standard prior authorization forms available from your physician's office.

Financial Assistance Options

Medicare Patients: Limited Manufacturer Support

Important limitation: Biogen's copay assistance programs exclude Medicare patients by federal law. This includes Humana Medicare Advantage and Part D plans.

However, other options exist:

Foundation Grant Programs:

Biogen Support Services (1-800-456-2255):

  • Insurance navigation assistance
  • Prior authorization support
  • Resource referrals (no direct copay assistance for Medicare)

Eligibility Requirements

Most foundation programs require:

  • Confirmed diagnosis
  • Financial hardship documentation
  • U.S. citizenship or legal residency
  • Active insurance coverage
  • Completion of assistance applications
From our advocates: "We've seen patients successfully combine foundation grants with careful timing of treatments to minimize out-of-pocket costs. One patient coordinated their infusion schedule to maximize their plan year benefits while maintaining clinical effectiveness."

Formulary Exception Process

If Tysabri isn't covered or faces restrictive requirements, you can request a formulary exception based on medical necessity.

Exception Request Requirements

Physician documentation must show:

  • All covered formulary alternatives would be less effective for this patient
  • Covered alternatives would cause adverse effects or contraindications
  • Patient-specific clinical factors requiring Tysabri specifically

Submission Process

  1. Physician initiates request through Humana's prior authorization system
  2. Medical necessity letter detailing why formulary drugs are inappropriate
  3. Clinical supporting evidence (labs, imaging, specialist consultations)
  4. Prior therapy documentation showing failures or intolerances

Timeline: Humana must respond within 72 hours for standard requests, 24 hours for expedited cases where delay poses serious health risks.

Specialty Pharmacy Requirements

Tysabri requires use of Humana-contracted specialty pharmacies due to TOUCH program requirements and special handling needs.

Key Requirements

  • No mail-order availability for standard pharmacy services
  • Limited network of authorized specialty pharmacies
  • Coordination required between pharmacy, infusion site, and TOUCH program
  • 30-day supply limits typical for specialty medications

Steps to coordinate specialty pharmacy:

  1. Contact Humana to identify in-network specialty pharmacies in your area
  2. Verify the pharmacy is TOUCH-enrolled
  3. Coordinate with your infusion center for delivery scheduling
  4. Confirm prior authorization is complete before first shipment

Appeals Process in Florida

If your initial Tysabri request is denied, Florida residents with Humana Medicare have specific appeal rights and timelines.

Internal Appeals Timeline

Appeal Level Who Reviews Standard Timeline Expedited Timeline
Initial Appeal Humana 7 days (Part D) / 30 days (Part C) 24-72 hours
Reconsideration Independent QIC 7-14 days 72 hours

Required Documentation for Appeals

Include with your appeal:

  • Original denial letter
  • Additional medical records supporting necessity
  • Physician letter explaining why denial should be overturned
  • Documentation of failed alternatives
  • Any new clinical evidence

External Review Options

After exhausting Humana's internal appeals, you can request external review through:

Medicare Appeals Process:

  • Office of Medicare Hearings and Appeals (for amounts ≥$190 in 2025)
  • Medicare Appeals Council
  • Federal Court (for higher amounts)

Florida Department of Financial Services:

  • Consumer Helpline: 1-877-693-5236
  • Email: [email protected]
  • Assistance with insurance complaints and appeal navigation

Filing Your Appeal

Submit appeals in writing within 65 days of the denial notice. Include:

  • Your name, member ID, and contact information
  • Copy of the denial letter
  • Reason you believe the denial was incorrect
  • Supporting medical documentation
  • Physician's medical necessity letter

Annual Renewal Planning

Plan ahead for continued Tysabri coverage as formularies and benefits can change annually.

Year-End Checklist (October-December)

  • Review next year's formulary for Tysabri placement changes
  • Check tier placement and cost-sharing updates
  • Verify specialty pharmacy network remains the same
  • Confirm TOUCH program enrollment stays current
  • Budget for potential cost changes

What Can Change

Annual variables:

  • Formulary tier placement
  • Prior authorization requirements
  • Specialty pharmacy networks
  • Coinsurance percentages
  • Deductible amounts

Stable elements:

  • TOUCH program requirements (FDA-mandated)
  • Medical necessity criteria
  • Appeal rights and timelines

Contact Humana in early fall to discuss any upcoming changes that might affect your Tysabri coverage.

Conversation Scripts

Calling Humana Customer Service

"Hi, I'm a Medicare member calling about prior authorization for Tysabri, also called natalizumab. My member ID is [number]. I need to understand the PA requirements, which specialty pharmacies are covered, and what documentation my doctor needs to submit. Can you also confirm if this drug is on my plan's formulary and what my cost-sharing will be?"

Provider Office Discussion

"I need Tysabri for my [MS/Crohn's disease], and my insurance requires prior authorization. Can you help me understand what documentation you'll need to submit? I'm also enrolled in the TOUCH program - do you have my enrollment information? What's the typical timeline for getting approval from Humana?"

Specialty Pharmacy Coordination

"I have a Tysabri prescription that needs to be filled through your specialty pharmacy. My insurance is Humana Medicare, and I believe the prior authorization is approved. Can you verify coverage, coordinate with my infusion center for delivery, and confirm the TOUCH program requirements are met?"

FAQ

How long does Humana prior authorization take for Tysabri? Standard PA decisions are made within 30 days for medical coverage (Part C) and 72 hours for drug coverage (Part D). Expedited reviews can be completed in 24-72 hours for urgent cases.

What if Tysabri isn't on my Humana formulary? You can request a formulary exception by having your physician document medical necessity and why all covered alternatives are inappropriate. The request must show covered drugs would be less effective or cause adverse effects.

Can I get expedited approval if I'm currently on Tysabri? Yes, if stopping treatment would pose serious health risks, you can request expedited prior authorization or appeal review. Include physician documentation of the urgent medical need.

Does Florida have additional appeal rights beyond Medicare? Florida residents can contact the Department of Financial Services for assistance with insurance complaints and appeal navigation, but Medicare appeals follow federal timelines and processes.

Are there quantity limits on Tysabri with Humana? Specialty medications often have quantity limits, typically 30-day supplies. Your specific limits depend on your plan and can be found in your Evidence of Coverage document.

What happens if I miss a TOUCH program requirement? TOUCH program non-compliance can result in immediate coverage denial. Work with your healthcare team to ensure all safety monitoring and reporting requirements are met continuously.

Can I appeal based on cost alone? Appeals must be based on medical necessity, not cost preferences. However, if high costs prevent you from accessing medically necessary treatment, this can be part of your appeal argument.

How do I find TOUCH-enrolled providers in Florida? Use the TOUCH program provider locator on the Tysabri website or contact Biogen Support Services at 1-800-456-2255 for assistance finding enrolled providers in your area.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer's specific workflow.

For complex cases like Tysabri appeals, having professional support to navigate payer-specific requirements and compile the necessary medical evidence can significantly improve approval outcomes. Counterforce Health's system is designed to meet the exact documentation standards that plans like Humana require while tracking deadlines and required attachments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies vary by plan and location. Always consult with your healthcare provider and insurance plan directly for the most current requirements and procedures. Coverage decisions are made by your insurance plan based on medical necessity and plan terms.

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