By Counterforce Health Team in Voydeya (danicopan) —

How to Get Voydeya (Danicopan) Covered by Humana in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Voydeya (Danicopan) Covered by Humana in Washington

Humana requires prior authorization for Voydeya (danicopan) for PNH treatment. The fastest path to approval: (1) Ensure your hematologist submits a complete prior authorization with PNH diagnosis by flow cytometry, documentation of extravascular hemolysis despite optimized C5 inhibitor therapy, and required vaccinations, (2) Submit via Humana's provider portal with decisions typically within 1 business day, (3) If denied, file an internal appeal within 65 days, then request external review through Washington's Office of the Insurance Commissioner within 60 days of final denial.

Table of Contents

Humana's Coverage Policy for Voydeya

Humana Medicare Advantage and Part D plans classify Voydeya (danicopan) as a specialty medication requiring prior authorization through their Clinical Pharmacy Review process. As a newly approved complement inhibitor for paroxysmal nocturnal hemoglobinuria (PNH), Voydeya falls under Humana's high-cost specialty drug protocols.

Plan Types Affected:

  • Medicare Advantage (Part C)
  • Medicare Part D prescription plans
  • Some commercial Humana plans (verify with your specific policy)

Where to Find Official Policies: Check Humana's prior authorization search tool and formulary documents. Policies update frequently for newly approved rare disease medications.

Medical Necessity Requirements

Humana's coverage criteria for Voydeya typically require documentation that aligns with FDA labeling and clinical evidence standards:

Core Requirements

  • Confirmed PNH diagnosis by flow cytometry showing GPI-anchored protein deficiency
  • Add-on therapy only - must be prescribed alongside a C5 inhibitor (eculizumab/Soliris or ravulizumab/Ultomiris)
  • Evidence of extravascular hemolysis despite optimized C5 inhibitor therapy
  • Specialist prescriber (hematologist or hematologist-oncologist)
  • Required vaccinations per safety protocols

Clinical Documentation Needed

  • Flow cytometry report demonstrating PNH clone size and GPI-protein deficiency on multiple cell lineages
  • Evidence of inadequate response to C5 inhibitor monotherapy (persistent anemia, elevated reticulocyte count, transfusion requirements)
  • Laboratory values supporting ongoing hemolysis (elevated LDH, indirect bilirubin, low haptoglobin)
  • Documentation of meningococcal, pneumococcal, and Haemophilus influenzae vaccinations

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Timeline: 1-2 days

  • Insurance card and policy details
  • Flow cytometry report confirming PNH diagnosis
  • Recent labs (CBC, reticulocyte count, LDH, bilirubin, haptoglobin)
  • Vaccination records
  • Documentation of current C5 inhibitor therapy and response

2. Prescriber Submits Prior Authorization (Clinic)

Timeline: Same day submission

  • Submit via Humana provider portal (preferred)
  • Alternative: Fax to 877-486-2621 (verify current number)
  • Include comprehensive medical necessity letter addressing all criteria

3. Humana Review Process

Timeline: 1 business day for electronic submissions

  • Standard review for non-urgent requests
  • Expedited review available if delay poses health risk
  • Decision notification via portal, phone, or mail

4. If Approved: Specialty Pharmacy Coordination

Timeline: 1-3 days

  • Humana will route prescription to contracted specialty pharmacy
  • Patient receives outreach for delivery coordination
  • First fill typically ships within 24-48 hours of approval

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Monotherapy request Clarify add-on use with C5 inhibitor Current C5 inhibitor prescription and dosing schedule
Insufficient EVH evidence Provide comprehensive hemolysis markers Recent labs showing anemia, high reticulocytes, elevated LDH despite C5 therapy
Missing vaccinations Submit vaccination records Documentation of required vaccines or medical contraindication
Non-specialist prescriber Transfer to hematologist Specialist evaluation and prescription
Inadequate PNH documentation Provide detailed flow cytometry Complete flow cytometry report with clone size quantification

Appeals Process in Washington

Washington state provides robust protection for patients facing insurance denials through a multi-level appeals process.

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Submission: Via Humana member portal, phone, or mail as specified in denial letter
  • Timeline: Humana has 30 days for standard appeals, 72 hours for expedited
  • Required: Original denial letter, additional clinical evidence, updated medical necessity letter
Tip: Request a peer-to-peer review where your hematologist speaks directly with Humana's medical director. This often resolves denials faster than formal appeals.

External Review (Washington State IRO)

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

  • Eligibility: Available after internal appeal completion or non-response
  • How to Request: Submit to Washington Office of the Insurance Commissioner
  • Deadline: 60 days after final Humana denial
  • Timeline: 20 days for standard review, 72 hours for expedited
  • Cost: Free to patient
  • Outcome: Binding decision - if overturned, Humana must provide coverage

Contact Washington OIC Consumer Advocacy: 1-800-562-6900 for assistance navigating appeals.

Required Documentation Checklist

For Initial Prior Authorization:

  • Current insurance card and policy information
  • Flow cytometry report confirming PNH diagnosis with clone size
  • Recent complete blood count (CBC) with differential
  • Reticulocyte count
  • Comprehensive metabolic panel including LDH and bilirubin
  • Haptoglobin level
  • Documentation of current C5 inhibitor therapy (drug, dose, frequency)
  • Vaccination records (meningococcal, pneumococcal, Hib)
  • Medical necessity letter from hematologist
  • Prior therapy trials and outcomes

For Appeals:

  • Original denial letter
  • Updated clinical notes
  • Recent laboratory values
  • Additional supporting literature or guidelines
  • Patient impact statement (optional but helpful)

Costs and Patient Support Options

Estimated Costs:

  • List price: Approximately $50,000-$100,000 annually (dose-dependent)
  • Combined with C5 inhibitor: Total regimen cost significantly higher

Patient Support Programs:

  • Alexion Patient Support: Contact 1-888-ALEXION for copay assistance and patient access programs
  • Washington State Programs: Check eligibility for state pharmaceutical assistance programs through the Washington State Health Care Authority
  • Foundation Support: Organizations like the HealthWell Foundation may provide grants for rare disease medications

When to Contact Washington State Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Humana fails to respond within required timeframes
  • You experience procedural violations during appeals
  • You need assistance navigating the external review process
  • You want to file a complaint about coverage practices

Contact Information:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Online complaint form available on their website

FAQ

How long does Humana prior authorization take for Voydeya in Washington? Electronic submissions typically receive decisions within 1 business day. Paper submissions may take up to 14 days. Expedited reviews are available when delay poses health risks.

What if Voydeya isn't on Humana's formulary? You can request a formulary exception by demonstrating medical necessity. This requires comprehensive documentation showing why formulary alternatives are inappropriate.

Can I request an expedited appeal if my condition is worsening? Yes. If delay in treatment poses serious health risks, you can request expedited review at both internal appeal and external review levels, with decisions typically within 72 hours.

Does Washington's external review apply to all Humana plans? Washington's external review applies to fully insured plans. Self-funded employer plans may have different processes, though many voluntarily use similar procedures.

What happens if the external reviewer overturns Humana's denial? The decision is binding on Humana. They must provide coverage for Voydeya according to the reviewer's determination.

How much does the appeals process cost in Washington? Internal appeals and external review through Washington's process are free to patients. You only pay for any additional medical records or documentation you choose to obtain.

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed requests that align with each payer's specific requirements. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes for rare disease medications like Voydeya, ensuring that critical treatments reach patients faster.

For comprehensive support with Voydeya prior authorization and appeals, Counterforce Health provides specialized tools and expertise to improve approval rates and reduce administrative burden.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by individual plan and change frequently. Always verify current requirements with your specific Humana plan and consult with your healthcare provider for medical decisions. For personalized assistance with Washington insurance appeals, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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