By Counterforce Health Team in Xospata (gilteritinib) —

How to Get Xospata (gilteritinib) Covered by Humana in New York: Prior Authorization Forms, Appeals Timeline, and Success Tips

Quick Answer: Xospata (gilteritinib) requires prior authorization from Humana in New York. Your hematologist must submit clinical documentation proving FLT3 mutation, relapsed/refractory AML status, and medical necessity. If denied, you have 65 days to appeal and can use New York's external review process. Start by confirming your prescriber is in-network and gathering FLT3 test results, prior therapy records, and bone marrow reports.

Table of Contents

  1. Humana Plan Types & Network Requirements
  2. Xospata Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Basics
  6. Step-by-Step: Fastest Path to Approval
  7. Common Denial Reasons & Solutions
  8. Appeals Process in New York
  9. When to Escalate to State Regulators
  10. FAQ

Humana Plan Types & Network Requirements

Humana offers several Medicare Advantage plan types in New York, each with different rules for accessing specialists and prescription drugs:

HMO Plans: Require referrals to see hematology/oncology specialists. You must use in-network providers exclusively (except for emergencies). Most common Humana Medicare Advantage option in New York.

PPO Plans: Allow you to see out-of-network specialists but with higher copays. No referrals needed for specialists like hematologists.

Network Verification: Before starting Xospata treatment, confirm your hematologist/oncologist is in Humana's network. In-network specialists typically have a $25 copay per visit in 2025, while out-of-network visits can cost significantly more.

Tip: Use Humana's online provider directory or call member services to verify your oncologist's network status before requesting prior authorization.

Xospata Formulary Status & Tier Placement

Xospata (gilteritinib) is covered under most 2024-2025 Humana Medicare Advantage plans but sits on the specialty drug tier, meaning:

  • Prior authorization required for all prescriptions
  • Specialty pharmacy dispensing only (not available at retail pharmacies)
  • Higher cost-sharing compared to generic medications
  • Medical necessity documentation must support FDA-approved indication

The drug costs approximately $28,979 for a 30-day supply (120mg daily dose), making prior authorization essential for coverage.

Prior Authorization Requirements

Humana requires comprehensive clinical documentation before approving Xospata. Your hematologist must submit:

Required Clinical Documentation

  • FLT3 mutation test results using FDA-approved LeukoStrat CDx assay
  • AML diagnosis confirmation with pathology reports and bone marrow biopsy
  • Relapsed/refractory status documentation showing disease progression or treatment failure
  • Prior therapy history including specific agents tried, duration, and reasons for discontinuation
  • Medical necessity letter explaining why Xospata is clinically appropriate

Submission Process

Submit prior authorization requests by faxing to 1-877-486-2621 or through Humana's provider portal. Include all supporting documentation in the initial submission to avoid delays.

Note: Incomplete submissions are the most common reason for prior authorization delays. Ensure all required documents are included before submitting.

Specialty Pharmacy Network

Xospata cannot be dispensed through regular retail pharmacies. Humana members must use:

CenterWell Specialty Pharmacy: Humana's preferred specialty pharmacy partner that coordinates directly with your oncologist and handles prior authorization paperwork.

Alternative Options: Other Xospata network specialty pharmacies may be available, but verify coverage with Humana first.

Patient Enrollment Process:

  1. Your prescriber submits the prescription to CenterWell or approved specialty pharmacy
  2. Pharmacy initiates prior authorization with Humana
  3. Once approved, medication is shipped directly to your home or clinic
  4. Follow-up coordination for refills and monitoring

Contact Xospata Support Solutions at 1-844-632-9272 for help coordinating pharmacy services.

Cost-Share Basics

Your out-of-pocket costs for Xospata depend on your specific Humana Medicare Advantage plan's benefit structure:

Typical Cost-Sharing Pattern:

  • Deductible: May apply before coverage begins (varies by plan)
  • Specialty tier coinsurance: Often 25-33% of drug cost after deductible
  • Maximum out-of-pocket: Medicare Advantage plans have annual limits that cap your total drug spending

Financial Assistance Options:

  • Astellas patient assistance programs may be available for eligible patients
  • Medicare Extra Help (Low Income Subsidy) can significantly reduce costs for qualifying individuals
  • State pharmaceutical assistance programs in New York may provide additional support

Step-by-Step: Fastest Path to Approval

1. Verify Network Status

Who: Patient or caregiver
Action: Confirm your hematologist is in Humana's network
Timeline: Same day
Source: Humana provider directory

2. Gather Required Documentation

Who: Oncology clinic staff
Action: Collect FLT3 test results, bone marrow reports, prior therapy records
Timeline: 1-2 business days
Source: Medical records department

3. Complete Prior Authorization Request

Who: Prescribing physician
Action: Submit PA form with supporting clinical documentation
Timeline: Submit within 24-48 hours of gathering documents
Source: Fax to 877-486-2621

4. Coordinate Specialty Pharmacy

Who: Clinic and patient
Action: Set up dispensing through CenterWell or approved specialty pharmacy
Timeline: Can be done concurrently with PA submission
Source: CenterWell Specialty Pharmacy

5. Track Decision Timeline

Who: Patient or clinic
Action: Follow up if no response within standard timeframes
Timeline: Standard PA decisions within 72 hours; expedited within 24 hours
Source: Medicare Part D regulations

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing FLT3 mutation test Submit FDA-approved assay results LeukoStrat CDx test report
Insufficient prior therapy documentation Provide detailed treatment history Clinic notes showing previous agents, dates, outcomes
Non-hematology prescriber Transfer prescription to qualified specialist In-network hematologist/oncologist
Front-line use (not relapsed/refractory) Document disease progression or treatment failure Bone marrow biopsy, imaging, lab values

Appeals Process in New York

If Humana denies your Xospata prior authorization, New York residents have strong appeal rights:

Internal Appeal (Redetermination)

External Review (New York State)

If Humana upholds the denial, you can request an external review through the New York Department of Financial Services:

  • Timeline: 4 months after final adverse determination
  • Cost: Maximum $25 fee (waived for financial hardship)
  • Decision: Binding on Humana if overturned
  • Expedited option: 72 hours for urgent cases; 24 hours for urgent drug denials
From our advocates: We've seen external reviews succeed when patients include peer-reviewed literature supporting Xospata's use in their specific clinical situation, along with a detailed letter from their hematologist explaining why covered alternatives wouldn't be appropriate. The key is presenting a comprehensive medical case, not just repeating the original prior authorization request.

When to Escalate to State Regulators

Contact New York regulators if:

  • Humana fails to meet decision timelines
  • Required appeal forms are unavailable
  • You suspect improper denial practices

New York Department of Financial Services
Consumer Assistance: File complaint online or call the consumer hotline

Community Health Advocates
Free insurance counseling: 888-614-5400
Assists with appeals and understanding coverage rights

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to create targeted, evidence-backed responses. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for medications like Xospata.

FAQ

How long does Humana prior authorization take for Xospata in New York?
Standard requests: 72 hours after receiving supporting documentation. Expedited requests: 24 hours if medically urgent.

What if Xospata is non-formulary on my Humana plan?
Request a formulary exception with your prescriber's supporting statement. Same 72-hour timeline applies for decisions.

Can I request an expedited appeal in New York?
Yes, if waiting could seriously jeopardize your health. New York allows expedited external appeals with 24-hour decisions for urgent drug denials.

Does step therapy apply to Xospata?
Typically no, since Xospata is specifically for relapsed/refractory AML after other treatments have failed. However, verify your specific plan requirements.

What counts as medical necessity for Xospata?
FDA-approved indication: adults with relapsed/refractory AML and confirmed FLT3 mutation (ITD or TKD) using an FDA-approved test.

Who can prescribe Xospata for Humana coverage?
Generally requires a hematologist/oncologist. Primary care physicians or non-oncology specialists may face additional scrutiny or denials.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized help with complex coverage issues, consider working with Counterforce Health, which provides targeted assistance with prior authorizations and appeals for specialty medications.

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