By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Humana in Illinois: Forms, Appeals, and Step Therapy Guide

Answer Box: Getting Tysabri (Natalizumab) Covered by Humana in Illinois

Humana requires prior authorization for Tysabri (natalizumab) and may apply step therapy requiring trial of preferred MS therapies first. To get covered: (1) Check your plan's formulary status at Humana's provider portal, (2) Submit PA documentation including MS diagnosis, prior DMT failures, JCV antibody status, and MRI reports through Humana's professionally administered drugs pathway, (3) If denied, file appeals within 65 days. Illinois residents have additional external review rights through the state insurance department within 30 days of final denial.

Table of Contents

Plan Types & Coverage Implications

Humana offers several plan types in Illinois, each with different coverage rules for Tysabri (natalizumab):

Medicare Advantage Plans: Most common for Illinois residents over 65. Tysabri is typically covered as a Part B (medical benefit) drug requiring prior authorization. Humana's 2024 Medicare Advantage denial rate was approximately 3.5%—among the lowest of major insurers—but denials often involve formulary placement or documentation gaps.

Commercial Plans: For employer-sponsored or individual market coverage. Coverage varies by specific contract but generally requires PA and may include step therapy requirements.

Medicaid Plans: Illinois expanded Medicaid covers Tysabri with prior authorization. Humana's Florida Medicaid PA list shows similar biologics require preauthorization (verify with Illinois-specific requirements).

Note: Network requirements apply differently—HMO plans require in-network neurologists and infusion centers, while PPO plans may allow out-of-network providers with higher cost-sharing.

Formulary Status & Tier Placement

Tysabri's coverage status depends on your specific Humana plan:

Coverage Verification Steps

  1. Check Plan-Specific Formulary: Use Humana's Medicare Drug List tool to search "natalizumab" or "Tysabri" for your exact plan
  2. Review PA Requirements: Check the Medicare Prior Authorization List for current restrictions
  3. Confirm Part B vs Part D: Tysabri is typically billed as a Part B infusion drug, not a retail prescription

Typical Formulary Placement

Plan Type Common Tier PA Required Step Therapy
Medicare Advantage Part B Medical Yes Often applies
Commercial Specialty Tier Yes Plan-specific
Medicaid Prior Auth Required Yes May apply

Source: Humana Provider Prior Authorization Lists

Prior Authorization Requirements

Humana requires comprehensive clinical documentation for Tysabri approval:

Required Clinical Documentation

Diagnosis Requirements:

  • Confirmed relapsing forms of multiple sclerosis
  • ICD-10 diagnosis code
  • Neurologist confirmation of disease type

Safety Monitoring:

  • JCV antibody test results (date and index value)
  • Baseline brain MRI report
  • TOUCH program enrollment confirmation
  • Planned monitoring schedule (MRI frequency, JCV retesting)

Medical Necessity Evidence:

  • Recent relapse history (dates, severity, steroid treatment)
  • MRI evidence of disease activity
  • Functional impact assessment (EDSS if available)

JCV Antibody Documentation

Humana reviewers typically expect:

  • Most recent JCV test date and result
  • For JCV-positive patients: index value and PML risk discussion
  • Monitoring plan: JCV testing every 6 months for negative patients
  • Risk-benefit analysis documented in clinical notes

MRI Requirements

Include with your PA submission:

  • Baseline brain MRI report showing lesion burden
  • Most recent MRI demonstrating disease activity or stability
  • Surveillance plan: Annual brain MRI minimum, more frequent for high-risk patients

Step Therapy & DMT Failure Documentation

Humana applies Part B step therapy to many MS biologics. However, patients already receiving Tysabri with a paid claim within 365 days are protected from new step therapy requirements.

Documenting DMT Failures

For each prior therapy, provide:

Treatment Details:

  • Drug name, dose, and duration
  • Start and stop dates
  • Reason for discontinuation

Failure Evidence:

  • Clinical relapses while on therapy (dates, symptoms, hospitalization)
  • MRI progression (new or enlarging T2 lesions, gadolinium enhancement)
  • Documented intolerance or adverse events

Common Preferred Alternatives:

  • Interferons (Avonex, Betaseron, Copaxone)
  • Oral DMTs (Tecfidera, Aubagio, Gilenya)
  • Other infused biologics (Ocrevus, Lemtrada)

Step Therapy Exception Process

If Tysabri is non-preferred:

  1. Document contraindications to preferred alternatives
  2. Request expedited review if clinically urgent
  3. Submit comprehensive failure history for required step therapies
  4. Include specialist letter explaining why alternatives are inappropriate

Specialty Pharmacy Network

CenterWell Specialty Pharmacy

Humana's owned specialty pharmacy, CenterWell, coordinates Tysabri distribution:

Patient Setup:

  • Call 1-800-486-2668 (TTY 711) to establish account
  • Register via MyHumana portal
  • Verify insurance coverage and copay assistance options

Provider Coordination:

TOUCH Program Requirements

All Tysabri prescribing requires TOUCH enrollment:

Required Enrollees:

  • Prescriber (neurologist)
  • Patient
  • Infusion site
  • Certified pharmacy

Enrollment Process:

  • Complete respective TOUCH forms
  • Fax to 1-800-840-1278
  • Await Patient Enrollment Number assignment
  • Coordinate with Biogen Case Manager

Appeals Process for Illinois Residents

Illinois provides robust appeal rights for insurance denials:

Humana Internal Appeals

Medicare Part D Timeline:

  • File within: 65 days of denial notice
  • Decision time: 7 days standard, 72 hours expedited
  • Submit via: Humana member portal or member services

Illinois External Review

If Humana upholds the denial, Illinois residents can request independent external review:

Timeline: 30 days from final denial (shorter than many states) Process: Independent Review Organization (IRO) with MS specialist Decision time: 5 business days after IRO receives materials Cost: Free to consumers

Illinois Resources:

Counterforce Health helps patients navigate complex insurance appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed appeals. Our platform identifies the specific denial basis and creates point-by-point rebuttals aligned to each plan's own rules, significantly improving approval rates for specialty medications like Tysabri.

Common Denial Reasons & Solutions

Denial Reason Documentation to Include Source
Missing TOUCH enrollment TOUCH confirmation, Patient Enrollment Number TOUCH Program Overview
Inadequate MRI documentation Baseline and recent brain MRI reports, surveillance plan Humana PA requirements
Step therapy not satisfied Prior DMT failure documentation, contraindication letters Humana Step Therapy List
JCV status unclear Recent JCV antibody results, risk-benefit analysis Standard MS monitoring guidelines
Off-label use FDA labeling confirmation, neurologist justification FDA prescribing information

Cost-Share Dynamics

Medicare Advantage: Typically 20% coinsurance after Part B deductible Commercial Plans: Varies by contract; may have specialty tier copays Medicaid: Minimal or no patient cost-sharing

Financial Assistance Options

Submission Mechanics

Required Forms and Portals

For Providers:

For Patients:

  • Use MyHumana portal for appeals
  • Call member services number on ID card for status updates
  • Keep copies of all submissions and confirmations

Critical Documentation Checklist

  • Completed PA form (plan-specific)
  • Neurologist letter with diagnosis and rationale
  • Prior DMT history with failure documentation
  • JCV antibody results and monitoring plan
  • Baseline and recent MRI reports
  • TOUCH enrollment confirmation
  • Insurance card and member ID verification

At Counterforce Health, we've seen that the most successful Tysabri appeals include comprehensive documentation addressing each plan's specific criteria, with particular attention to step therapy requirements and safety monitoring protocols that payers expect for high-risk biologics.

FAQ

How long does Humana PA take for Tysabri in Illinois? Standard PA decisions: 7-14 days. Expedited reviews (when delay may jeopardize health): 72 hours. Source: Medicare Part D appeals process.

What if Tysabri is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include prior therapy failures and contraindications to formulary alternatives.

Can I get expedited approval? Yes, if your neurologist certifies that delay may seriously jeopardize your health or ability to regain function. Mark PA requests as "expedited."

Does step therapy apply if I'm already on Tysabri? No, if you have a paid Tysabri claim within the past 365 days, Humana's step therapy policy protects existing users.

What's the difference between internal and external appeals in Illinois? Internal appeals are decided by Humana within 7 days. External appeals involve an independent physician reviewer and must be requested within 30 days of Humana's final denial.

How do I verify my infusion center is in-network? Use Humana's provider finder or call member services. Ensure both the facility and administering physician are credentialed with Humana.

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 clinical circumstances. Always consult your healthcare provider and insurance plan directly for specific coverage questions. For additional assistance with Illinois insurance appeals, contact the Illinois Department of Insurance at 877-527-9431.

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