By Counterforce Health Team in Xywav (Ca/Mg/K/Na oxybates) —

How to Get Xywav Covered by Humana in Florida: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Xywav Covered by Humana in Florida

Fastest Path to Approval: 1) Confirm your prescriber and you are enrolled in the FDA-required REMS program, 2) Submit comprehensive prior authorization via Humana's provider portal with sleep study results, ICD-10 codes (G47.4 for narcolepsy, G47.11 for idiopathic hypersomnia), and documented Xyrem failure/intolerance, 3) If denied, file an appeal within 65 days using Humana's online portal or by calling 1-800-457-4708. Most approvals require step therapy completion first.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timeline
  6. If You're Asked for More Information
  7. If Your Request is Denied: Appeals in Florida
  8. Common Denial Reasons & How to Fix Them
  9. Renewal and Re-authorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This guide helps Florida residents with Humana Medicare Advantage or Part D coverage navigate the prior authorization process for Xywav (calcium, magnesium, potassium, sodium oxybates). Whether you're dealing with narcolepsy or idiopathic hypersomnia, we'll walk you through each step from initial submission to appeals if needed.

Xywav is a specialty medication that requires strict controls due to its potential for abuse. Humana requires prior authorization for all oxybate medications, with additional step therapy requirements in most cases.

Who this helps: Patients diagnosed with narcolepsy or idiopathic hypersomnia, their caregivers, and healthcare providers seeking Humana coverage for Xywav in Florida.

Before You Start: Verify Your Coverage

Check Your Plan Type

First, confirm whether you have Humana Medicare Advantage (Part C) or standalone Part D coverage. The prior authorization process is similar, but contact information and some timelines may differ.

  • Find your plan details: Log into your MyHumana account or call the number on your insurance card
  • Verify Xywav is covered: Check your plan's formulary (drug list) to see which tier Xywav is placed on—typically it's a high-tier specialty medication

Confirm Network Status

Ensure your prescribing physician is in-network with Humana. Out-of-network prescribers may face additional hurdles or require you to pay higher costs.

Understand the REMS Requirement

Both you and your prescriber must be enrolled in the Xywav and Xyrem REMS program before any prescription can be filled. This is an FDA requirement that cannot be waived.

Gather What You Need

Essential Documentation

Diagnosis Documentation:

  • For Narcolepsy: ICD-10 codes G47.411 (with cataplexy) or G47.419 (without cataplexy)
  • For Idiopathic Hypersomnia: ICD-10 code G47.11
  • Sleep study results showing mean sleep latency ≤8 minutes on MSLT
  • For narcolepsy: ≥2 sleep-onset REM periods documented
  • For idiopathic hypersomnia: <2 sleep-onset REM periods

Prior Therapy Records:

  • Documentation of Xyrem (sodium oxybate) trial and failure/intolerance
  • Records of stimulant trials (modafinil, armodafinil, methylphenidate, etc.)
  • Any adverse reactions or contraindications to previous treatments

Clinical Justification:

  • Physician notes explaining why lower-sodium oxybate is medically necessary
  • Cardiovascular, renal, or other conditions that make sodium restriction important
  • Functional assessment showing impact of symptoms on daily life

REMS Program Documentation

  • Confirmation that both patient and prescriber are enrolled in the REMS program
  • REMS enrollment forms (if not already completed)

Submit the Prior Authorization Request

Submission Methods

Preferred Method - Online Portal: Humana's provider portal offers the fastest processing. Your doctor's office can submit requests electronically with all supporting documents attached.

Alternative Methods:

Clean Request Packet Checklist

✓ Completed prior authorization form ✓ Sleep study results (PSG and MSLT) ✓ ICD-10 diagnosis codes ✓ Documentation of prior Xyrem trial ✓ Clinical notes supporting medical necessity ✓ REMS enrollment confirmation ✓ Prescription with exact dosing

Tip: Incomplete submissions are the #1 cause of delays. Double-check that all required documents are included before submitting.

Follow-Up and Timeline

Standard Processing Times

  • Standard prior authorization: Up to 30 days for Medicare Advantage
  • Part D coverage determinations: 7 calendar days
  • Expedited reviews: 72 hours (24 hours if urgent)

When to Follow Up

Call Humana Member Services at 1-800-457-4708 if you haven't received a decision within:

  • 5 business days for expedited requests
  • 14 calendar days for standard requests

Sample Call Script: "Hi, I'm calling to check the status of a prior authorization request for Xywav submitted on [date]. My member ID is [number]. Can you provide an update and let me know if any additional information is needed?"

Document everything: Keep notes of call dates, reference numbers, and representative names.

If You're Asked for More Information

Humana may request additional clinical information to support medical necessity. Common requests include:

  • More detailed sleep study interpretation
  • Additional documentation of Xyrem failure
  • Peer-reviewed literature supporting off-label use (if applicable)
  • Updated clinical notes showing current symptom severity

Respond promptly to these requests—delays can reset the review timeline.

Clinician Corner: When writing medical necessity letters, include specific details about sleep latency times, SOREMP counts, previous medication trials with dates and outcomes, and how sodium restriction benefits this specific patient's comorbid conditions.

If Your Request is Denied: Appeals in Florida

Understanding Your Appeal Rights

In Florida, you have strong appeal rights under both state and federal law. Humana Medicare members have 65 days from the denial notice to file an appeal.

Level 1: Internal Appeal (Redetermination)

How to File:

  • Online: Through your MyHumana account
  • Phone: 1-800-457-4708 (TTY: 711)
  • Mail: Address provided in your denial letter

Timeline: Humana must respond within 7 calendar days for Part D appeals.

Level 2: External Review

If Humana upholds the denial, you can request an external review through Florida's Department of Financial Services. This independent review is free and the decision is binding on Humana.

How to Request:

  • Contact Florida Division of Consumer Services at 1-877-693-5236
  • File online through the DFS consumer complaint portal
  • You have 4 months after the final internal denial to request external review

For urgent cases, expedited external reviews can be completed within 72 hours.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Step therapy not completed Document Xyrem trial and failure/intolerance Medical records showing adverse reactions, lack of efficacy, or contraindications
Insufficient diagnosis documentation Provide complete sleep study results MSLT with specific sleep latency and SOREMP counts
Not medically necessary Submit clinical justification for sodium restriction Cardiology/nephrology notes supporting low-sodium need
REMS enrollment missing Complete REMS program enrollment REMS confirmation for both patient and prescriber
Quantity limits exceeded Request medical exception with clinical rationale Documentation supporting higher dose requirement

Renewal and Re-authorization

Most Xywav approvals require renewal every 6-12 months. Calendar these dates and start the renewal process 30-45 days before expiration.

Renewal Documentation:

  • Updated clinical notes showing continued benefit
  • Confirmation of ongoing REMS compliance
  • Any new relevant test results or clinical changes

Quick Reference Checklist

Before Starting:

  • Verify Humana coverage and formulary placement
  • Confirm prescriber is in-network
  • Complete REMS enrollment (patient and prescriber)

For Submission:

  • Sleep study results with specific measurements
  • ICD-10 diagnosis codes (G47.4 or G47.11)
  • Documentation of Xyrem trial
  • Clinical justification for low-sodium formulation
  • Complete prior authorization form

After Submission:

  • Follow up within 14 days if no response
  • Respond quickly to requests for additional information
  • File appeal within 65 days if denied
  • Calendar renewal dates

FAQ

How long does Humana prior authorization take for Xywav in Florida? Standard reviews take up to 7 days for Part D, 30 days for Medicare Advantage. Expedited reviews are completed within 72 hours.

What if Xywav isn't on my Humana formulary? You can request a formulary exception with strong clinical justification. This requires demonstrating medical necessity and that covered alternatives are inappropriate.

Can I get an expedited appeal if my Xywav is denied? Yes, if you can demonstrate that waiting for a standard appeal timeline would seriously jeopardize your health. Your doctor must support the urgency request.

Does step therapy apply if I tried Xyrem outside of Florida? Yes, documented trials from any state count toward step therapy requirements, as long as you have medical records proving the trial and outcome.

What's the difference between Humana Medicare Advantage and Part D appeals? The process is similar, but Part D appeals have shorter timelines (7 days vs 30 days) and different contact numbers may apply.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that speak directly to payers' own criteria. For complex cases like Xywav approvals, having expert support can make the difference between approval and prolonged delays.

Sources & Further Reading

This guide provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions. For personalized help with your specific situation, contact Counterforce Health or speak with a Florida SHIP counselor through shiphelp.org.

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