By Counterforce Health Team in Voydeya (danicopan) —

How to Get Voydeya (Danicopan) Covered by Humana in Pennsylvania: Complete Appeals Guide

Quick Answer: Getting Voydeya Covered by Humana in Pennsylvania

Voydeya (danicopan) requires prior authorization from Humana Medicare Advantage/Part D plans. Your fastest path: Have your hematologist submit a PA request through Humana's provider portal or CoverMyMeds with documentation of PNH diagnosis, failed/inadequate C5 inhibitor therapy, and evidence of extravascular hemolysis. If denied, appeal within 65 days using Humana's redetermination process, then escalate to Pennsylvania's Independent External Review if needed. Start today by verifying your plan type and gathering lab results showing persistent anemia despite C5 therapy.

Table of Contents

  1. Verify Your Plan & Coverage Requirements
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Options
  4. Fax & Mail Submission Details
  5. Specialty Pharmacy Network & Enrollment
  6. Support Lines & Contact Numbers
  7. Pennsylvania External Review Process
  8. Appeals Playbook: Step-by-Step
  9. Common Denial Reasons & Solutions
  10. Costs & Patient Assistance

Verify Your Plan & Coverage Requirements

Before starting your Voydeya (danicopan) approval process, confirm your specific Humana plan type. Voydeya requires prior authorization across all Humana Medicare Advantage and Part D plans due to its high cost (approximately $50,000-$100,000 annually) and specialized indication for paroxysmal nocturnal hemoglobinuria (PNH).

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all Humana MA/Part D plans Humana PA Search Tool
Formulary Status Check current formulary; likely specialty tier Humana Drug Lists
Age Requirement 18+ years for FDA indication FDA Access Data
Prescriber Hematologist/specialist preferred Humana Policy
Diagnosis PNH confirmed by flow cytometry FDA Label

Use Humana's Prior Authorization Search Tool to confirm current PA requirements by entering "danicopan" or "Voydeya" and selecting Pennsylvania.

Prior Authorization Forms & Requirements

Required Documentation

For Humana Medicare Part D coverage, Voydeya requires comprehensive clinical documentation:

Essential Clinical Evidence:

  • PNH diagnosis confirmed by flow cytometry
  • Current C5 inhibitor therapy (eculizumab/Soliris or ravulizumab/Ultomiris)
  • Evidence of extravascular hemolysis (EVH) despite C5 therapy:
    • Hemoglobin ≤9.5 g/dL
    • Elevated reticulocyte count (≥120 ×10⁹/L)
    • LDH levels and transfusion requirements
  • Duration of C5 inhibitor therapy (typically ≥6 months required)
  • Vaccination status (meningococcal, pneumococcal, Haemophilus influenzae type b)

Key Forms:

Clinician Corner: Your medical necessity letter should emphasize that Voydeya is used in addition to (not instead of) C5 inhibitor therapy. Include specific lab values showing persistent EVH and any transfusion requirements or quality-of-life impacts from ongoing anemia.

Submission Portals & Electronic Options

Primary Electronic Submission Methods

1. Availity Provider Portal

  • Log in at provider.humana.com
  • Navigate to Prior Authorizations → Pharmacy PA
  • Upload clinical documentation and complete Part D coverage determination request

2. CoverMyMeds Electronic PA

  • Access through CoverMyMeds Humana portal
  • Select Humana as payer and complete electronic PA workflow
  • Attach clinical notes, labs, and prescriber attestation

3. Member-Initiated Online Request

Timeline Expectations

  • Electronic submissions: Processed within 1 business day for ~95% of requests (Humana's 2026 commitment)
  • Standard determination: 7 calendar days for Part D decisions
  • Expedited: 72 hours for urgent/life-threatening situations

Fax & Mail Submission Details

If electronic submission isn't available, use these verified contact methods:

Fax Numbers:

  • Medicare Part D PA requests: Use fax number provided on current "Request for Medicare Prescription Drug Coverage Determination" form
  • General pharmacy PA: Contact Humana Clinical Pharmacy Review team (number available through provider portal)

Mailing Address: Check the current Part D coverage determination form for the most up-to-date mailing address, as these can change annually.

Cover Sheet Tips:

  • Mark "URGENT" for expedited requests
  • Include member ID, prescriber NPI, and "Voydeya (danicopan) PA Request"
  • List all attached documents (lab results, clinical notes, REMS enrollment)

Specialty Pharmacy Network & Enrollment

Important: Onco360 is the Exclusive Partner

Voydeya is only available through Onco360, not Humana's CenterWell Specialty Pharmacy network. This is a manufacturer requirement.

Enrollment Steps:

  1. REMS Program Registration: Prescriber must enroll at voydeyahcp.com
  2. Patient Support Program: Enroll through Alexion OneSource for benefits verification and PA assistance
  3. Onco360 Setup: Call 1-888-562-6362 to establish patient profile and coordinate with Humana coverage

Transfer Process: If transferring from another pharmacy, Onco360 will coordinate the transfer once Humana PA approval is obtained. Provide your Humana member ID and PA approval documentation.

Note: While Onco360 handles dispensing, Humana's standard PA and coverage determination processes still apply. CenterWell Specialty Pharmacy (1-833-412-1197) can assist with Humana-specific coverage questions.

Support Lines & Contact Numbers

Key Contact Information

Humana Member Services:

  • Number on your member ID card for general coverage questions
  • Part D Appeals: 1-800-867-6601 (expedited appeals available)

Specialty Support:

  • Onco360 (Voydeya dispensing): 1-888-562-6362
  • Alexion OneSource (PA support): 1-888-765-4747
  • CenterWell Specialty (Humana coordination): 1-833-412-1197

When to Call:

  • Member Services: Plan verification, formulary status, general PA questions
  • Onco360: Prescription transfers, delivery scheduling, insurance coordination
  • Alexion OneSource: PA documentation support, benefits verification, appeals assistance

Pennsylvania External Review Process

Pennsylvania's Independent External Review (IER) program, launched January 2024, provides a powerful appeal option after exhausting Humana's internal process.

Key Statistics & Success Rates

  • 53% overturn rate in first year of operation
  • 259 successful appeals out of 517 filed in 2024
  • No cost to consumers

Eligibility & Process

Important: Pennsylvania's external review applies to commercial plans, but Medicare Advantage appeals follow federal CMS processes. However, if you have additional commercial coverage or if your case involves state-regulated aspects, you may be eligible.

Timeline:

  1. Exhaust Humana internal appeals (65 days from denial)
  2. File IER request within 4 months of final denial
  3. PID review: 5 business days for eligibility determination
  4. IRO assignment: Within 15 business days
  5. Decision: 45 calendar days (standard) or 72 hours (expedited)

How to File:

Appeals Playbook: Step-by-Step

Level 1: Internal Appeal (Redetermination)

Timeline: Within 65 days of Humana's denial notice

Required Form: "Request for Redetermination of Medicare Prescription Drug Denial"

Submission Options:

  • Online through Humana member portal
  • Fax: 1-877-486-2621 (mainland) or 1-855-681-8650 (Puerto Rico)
  • Phone: 1-800-867-6601 (expedited available)

Decision Timeline: 7 calendar days (72 hours for expedited)

Level 2: Independent Review Entity (IRE)

If Humana upholds the denial, escalate to Medicare's Independent Review Entity within 60 days.

Level 3: Administrative Law Judge (ALJ)

Available if the dollar amount meets Medicare's threshold ($1,900 for 2025).

From our advocates: In our experience with PNH medication appeals, the most successful cases include detailed lab trend data showing persistent anemia despite optimized C5 inhibitor therapy, along with specialist letters explaining the specific mechanism of extravascular hemolysis. Don't just state that other treatments failed—show the clinical progression and explain why Voydeya's Factor D inhibition addresses the remaining hemolysis pathway.

Common Denial Reasons & Solutions

Denial Reason Documentation to Provide Where to Find It
"Not medically necessary" Lab trends, transfusion records, QOL impact Hematologist notes, hospital records
"Experimental/investigational" FDA approval letter, official indication FDA Access Data
"Missing prior authorization" Completed PA form with clinical justification Humana PA portal
"Step therapy not met" Documentation of C5 inhibitor trial and inadequate response Treatment history, lab results
"Non-formulary drug" Request formulary exception with medical necessity Humana exceptions process

Costs & Patient Assistance

Financial Support Options

Manufacturer Programs:

  • Alexion OneSource: Comprehensive support including benefits verification, PA assistance, and potential financial aid
  • Contact: 1-888-765-4747 or alexionaccessnavigator.com/voydeya

Medicare Part D Coverage:

  • Once approved, standard Part D cost-sharing applies
  • May qualify for Low Income Subsidy (LIS) programs
  • Medicare Part D catastrophic coverage threshold may apply given high cost

Additional Resources:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD) patient assistance programs
  • State pharmaceutical assistance programs (Pennsylvania PACE/PACENET for eligible seniors)

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Voydeya. Our platform analyzes denial letters, identifies specific payer requirements, and generates evidence-backed appeals that address each payer's unique criteria. For PNH treatments, we help clinicians navigate the complex documentation requirements around C5 inhibitor therapy, extravascular hemolysis evidence, and REMS program compliance.

Frequently Asked Questions

How long does Humana prior authorization take for Voydeya? Standard timeline is 7 calendar days for Medicare Part D decisions. Expedited reviews (for urgent situations) are completed within 72 hours.

What if Voydeya isn't on Humana's formulary? Request a formulary exception through Humana's drug exceptions process. Your prescriber must provide medical necessity documentation explaining why formulary alternatives are inappropriate.

Can I get expedited approval if I'm currently hospitalized? Yes, if the delay poses a serious threat to your health or life. Mark all submissions "EXPEDITED" and call 1-800-867-6601 to request urgent processing.

Does Pennsylvania's external review apply to Medicare Advantage? Medicare Advantage follows federal CMS appeal processes, but Pennsylvania's program may apply if you have additional commercial coverage or state-regulated plan components.

What vaccination requirements apply to Voydeya? You must be up-to-date on meningococcal, pneumococcal, and Haemophilus influenzae type b vaccines before starting therapy, as documented through the REMS program.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may vary by plan and can change. Always verify current requirements with your specific Humana plan and consult with your healthcare provider regarding treatment decisions. For personalized assistance with appeals, consider consulting with patient advocacy services or Counterforce Health.

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