By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (Ravulizumab) Covered by Humana in California: Complete Appeals Guide with Forms and Timelines

Quick Answer: Getting Ultomiris Covered by Humana in California

If Humana denies Ultomiris (ravulizumab), you have strong appeal rights in California. First step: Request a formulary exception within 65 days using Humana's coverage determination form. Include detailed medical necessity documentation from your prescriber. If denied again, escalate to California's Independent Medical Review (IMR) through the DMHC—decisions are binding on insurers. California's step therapy protections and "deemed approved" rules work in your favor when plans don't respond within required timeframes.

Start today: Call Humana member services (number on your ID card) to confirm Ultomiris's formulary status and request the coverage determination form.

Table of Contents

Why California State Rules Matter

California offers some of the strongest patient protections in the nation for specialty drug coverage. Unlike many states, California requires health plans to grant step therapy exceptions when medically appropriate, provides binding Independent Medical Review (IMR) decisions, and enforces strict timelines for prior authorization responses.

For Humana Medicare Advantage members, these protections work alongside federal Medicare regulations. If you have a commercial Humana plan through Covered California or your employer, California's Department of Managed Health Care (DMHC) regulations provide additional safeguards.

Key advantage: California's "deemed approved" rule means if Humana doesn't respond to your prior authorization request within required timeframes, the request is automatically approved.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for Ultomiris Humana formulary Humana Drug Lists
Formulary Tier Likely non-formulary or high-tier Member portal Humana Member Portal
Step Therapy May require trying alternatives first Plan documents California Override Laws
Appeal Deadline 65 days from denial Denial letter Humana Appeals Process
DMHC IMR Available after internal appeal DMHC website DMHC Help Center

Step-by-Step: Fastest Path to Approval

1. Confirm Coverage Status

Who: You or your prescriber
Action: Check if Ultomiris is on Humana's formulary
Timeline: Same day
Source: Humana formulary search tool

2. Gather Required Documentation

Who: Your healthcare team
Documents needed:

  • Complete diagnosis with ICD-10 codes
  • Prior treatment history and failures
  • Clinical notes supporting medical necessity
  • Lab results confirming diagnosis
  • REMS vaccination records (meningococcal)

3. Submit Prior Authorization Request

Who: Prescriber's office
Form: Humana Request for Medicare Prescription Drug Coverage Determination
Submit to: Humana pharmacy services (fax number on form)
Timeline: Submit within 15 days of prescription
Source: Humana PA forms

4. Follow Up on Timeline

Standard review: 30 days for pre-service requests
Expedited review: 72 hours if urgent
Action: If no response within timeline, request is deemed approved under California law

5. Appeal if Denied

Deadline: 65 days from denial notice
Submit to: Humana Grievance and Appeal Department
Address: P.O. Box 14165, Lexington, KY 40512-4165
Include: Additional clinical documentation, peer-reviewed studies supporting use

6. Request California IMR if Needed

When: After exhausting Humana's internal appeals
Contact: DMHC Help Center at 888-466-2219
Timeline: Decision within 45 days (7 days for urgent cases)
Source: DMHC IMR process

Understanding Turnaround Standards

Humana Response Times

  • Pre-service (before treatment): 30 calendar days
  • Post-service (after treatment): 60 calendar days
  • Expedited requests: 72 hours maximum
  • Appeals: 30 days for pre-service, 60 days for post-service

California's "Deemed Approved" Protection

If Humana fails to respond within these timeframes, California law considers your request automatically approved. Document all submission dates and follow up promptly if deadlines pass.

Source: California step therapy regulations

Step Therapy Protections

California's AB 347 provides strong protections against inappropriate step therapy requirements. You can request an override if:

  • You've previously tried and failed the required medication
  • The step therapy drug is likely to be ineffective based on your medical history
  • You've had adverse reactions to similar medications
  • You're stable on Ultomiris and switching would pose clinical risks

Documentation for Step Therapy Override

Your prescriber should include:

  • Specific prior medications tried and outcomes
  • Clinical reasons why alternatives are inappropriate
  • Risk assessment of delaying Ultomiris treatment
  • Reference to FDA labeling and clinical guidelines

Appeals Playbook for Humana

Level 1: Internal Appeal (Redetermination)

  • Timeline: Submit within 65 days of denial
  • Decision timeframe: 30 days (pre-service) or 60 days (post-service)
  • Required: Written request with supporting documentation
  • Tip: Include new clinical information not in the original request

Level 2: Independent Review Entity (Medicare)

  • When: After Humana upholds denial
  • Timeline: Automatic referral for Medicare Advantage members
  • Cost: Free to member
  • Decision: Binding on Humana

California-Specific: DMHC Complaint

For commercial plans or additional protection:

  • Contact: 888-466-2219
  • Process: File complaint if appeal timelines aren't met
  • Enforcement: DMHC can fine plans for violations

Source: DMHC complaint process

California External Review Process

California's Independent Medical Review (IMR) provides binding external review for denied treatments. While success rates for specialty drugs average around 10-12%, rare disease treatments with strong clinical documentation have better outcomes.

When IMR Applies

  • Treatment denied as "not medically necessary"
  • Experimental/investigational determinations
  • Disputes over emergency or out-of-network services

IMR Timeline

  • Application deadline: No specific deadline after internal appeal
  • Decision timeframe: 45 days standard, 7 days expedited
  • Cost: Free to patients
  • Decision: Binding on health plan

Source: DMHC IMR statistics

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Not medically necessary" Submit FDA labeling, clinical guidelines, peer-reviewed studies
"Experimental/investigational" Reference FDA approval date and indication-specific data
Step therapy not completed Request override with clinical justification
Dosing exceeds guidelines Provide weight-based calculations and specialist recommendations
REMS requirements not met Submit vaccination records and monitoring plan
From our advocates: We've seen cases where initial denials for complement inhibitors like Ultomiris were overturned when prescribers included specific lab values (like LDH levels for PNH) and detailed documentation of prior treatment failures. The key is connecting your clinical picture directly to FDA-approved indications and established treatment guidelines.

When to Escalate to State Regulators

Contact the California Department of Managed Health Care if:

  • Humana doesn't respond within required timeframes
  • Appeals are inappropriately denied
  • You encounter procedural violations

DMHC Help Center: 888-466-2219
Online complaints: healthhelp.ca.gov

The DMHC has enforcement authority and has issued significant fines to insurers for coverage violations, including a $300,000 penalty to Blue Shield in 2025 for claims handling issues.

Source: DMHC enforcement actions

Costs & Patient Assistance

Ultomiris costs approximately $474,000-$569,000 annually. Patient assistance options include:

Manufacturer Support

  • Alexion Access Navigator: Coverage support and copay assistance
  • Website: alexionaccessnavigator.com
  • Eligibility: Varies by insurance type and income

Foundation Assistance

  • Patient Access Network (PAN) Foundation
  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation

California-Specific Programs

  • Medi-Cal coverage for eligible low-income residents
  • Covered California premium subsidies and cost-sharing reductions

FAQ

How long does Humana prior authorization take for Ultomiris in California? Standard review is 30 days for pre-service requests. Expedited review (72 hours) is available if delays would seriously jeopardize your health. California's "deemed approved" rule applies if Humana doesn't respond within these timeframes.

What if Ultomiris is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are ineffective or inappropriate. Include detailed clinical documentation from your prescriber.

Can I request an expedited appeal in California? Yes, both Humana and California regulations allow expedited review when delays could seriously harm your health. Mark all requests as "URGENT" and provide clinical justification for the expedited timeline.

Does California step therapy protection apply to Medicare Advantage? California step therapy override laws primarily apply to state-regulated plans. However, Medicare Advantage plans must follow federal protections, and you can appeal step therapy requirements through Medicare's appeals process.

What happens if my Humana appeal is denied? Medicare Advantage members automatically receive independent review through Medicare's process. Commercial plan members can request California IMR through the DMHC. Both processes provide binding decisions on insurers.

How does Counterforce Health help with Ultomiris appeals? Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals with the right clinical evidence and procedural requirements for your specific payer and situation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For personalized appeals assistance, Counterforce Health provides evidence-backed support for turning denials into approvals.

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