By Counterforce Health Team in Alecensa (alectinib) —

How to Renew Alecensa (alectinib) Coverage with Humana in Virginia: Timeline, Documentation, and Appeals Process

Answer Box: Renewing Alecensa (alectinib) with Humana in Virginia

Renewal timing: Start 30-60 days before your current authorization expires. Required documents: Updated oncologist letter showing stable disease/response, recent imaging, liver function tests, and continued ALK-positive status confirmation. Timeline: Humana provides decisions within 72 hours (24 hours if expedited). First step: Contact your oncologist to gather current treatment response data and submit renewal through Humana's provider portal. If denied, Virginia residents have 120 days for external review through the State Corporation Commission's Bureau of Insurance.

Table of Contents

When to Start Your Renewal

Your Alecensa (alectinib) prior authorization renewal shouldn't wait until the last minute. Here are the key triggers that signal it's time to begin:

Start 30-60 days early if you're on a standard 12-month authorization. This buffer accounts for potential documentation delays and gives you time to appeal if initially denied.

Immediate renewal needed if you've had:

  • Dose adjustments outside the approved range
  • Treatment interruptions longer than 30 days
  • Changes in your cancer staging or diagnosis
Tip: Set a calendar reminder for 45 days before your expiration date. Your pharmacy may also notify you when refills are getting low, but don't rely on this alone.

Most Humana Medicare Advantage plans approve Alecensa renewals for 12 months when clinical response is documented. However, some may require 6-month reviews for new patients or those with treatment modifications.

Required Documentation Update

Your renewal packet must demonstrate ongoing medical necessity and treatment response. Here's what your oncologist needs to provide:

Clinical Response Documentation

  • Latest imaging results (CT, PET scan) showing stable disease, partial response, or complete response
  • Performance status assessment and quality of life measures
  • Tolerance profile including any grade 2+ adverse events and management strategies

Laboratory Monitoring

Since Alecensa requires ongoing liver function monitoring, include:

  • Recent liver function tests (AST, ALT, total bilirubin) from the past 30 days
  • Creatine phosphokinase (CPK) levels if elevated previously
  • Complete blood count if cytopenias have occurred

Treatment History Update

  • Adherence documentation showing consistent medication taking
  • Any dose modifications and clinical rationale
  • Concurrent medications and drug interaction assessments
Note: Genentech provides renewal documentation templates that align with most payer requirements.

Renewal Submission Process

For Healthcare Providers

  1. Log into Humana's provider portal or use their prior authorization fax line
  2. Complete the renewal form with updated clinical information
  3. Attach all supporting documentation listed above
  4. Specify renewal request rather than initial authorization
  5. Include expedited review request if treatment interruption poses clinical risk

For Patients

If your doctor's office needs assistance:

  • Call Humana Member Services at the number on your insurance card
  • Request a renewal form for Alecensa (alectinib)
  • Coordinate with your oncology team to ensure complete documentation

The key difference between initial authorization and renewal is demonstrating continued benefit rather than just eligibility for treatment.

Decision Timeline

Humana follows Medicare Part D regulations for specialty drug decisions:

Review Type Timeline When Available
Standard Review 72 hours Most renewals
Expedited Review 24 hours Medical urgency documented
Appeal Decision 7 days After initial denial

Expedited review criteria: Your oncologist must certify that a 72-hour delay could "seriously jeopardize your life, health, or ability to regain maximum function."

If you don't receive a decision within these timeframes, you can file a complaint with Humana or escalate to Virginia's external review process.

If Your Coverage Lapses

Treatment interruptions can affect cancer outcomes, so act quickly if your authorization expires:

Immediate Steps

  1. Contact Genentech Access Solutions at 888-249-4918 for potential bridging supply
  2. File an expedited appeal if the lapse was due to processing delays
  3. Request retroactive coverage for any gap period

Bridge Options

  • Patient Assistance Program: Free medication for uninsured/underinsured patients meeting income criteria
  • Co-pay Assistance: For commercial insurance holders (not available for Medicare patients)
  • Independent foundation referrals: Genentech can connect Medicare patients with charitable foundations

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed responses. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeal processes for specialty medications like Alecensa.

Clinical Safety During Gaps

Never stop Alecensa abruptly without oncologist guidance. If treatment must be interrupted for insurance reasons, your doctor will determine if temporary alternative monitoring or bridging therapy is needed.

Annual Plan Changes to Monitor

Humana can modify coverage policies annually, affecting your renewal:

Formulary Changes

  • Tier placement shifts: Moving from Tier 4 to Tier 5 increases costs
  • New step therapy requirements: May require trying other ALK inhibitors first
  • Quantity limit modifications: Could affect your dosing schedule

Prior Authorization Updates

Check Humana's annual formulary updates (usually published in October) for:

  • New clinical criteria
  • Additional documentation requirements
  • Changes to renewal frequency
Tip: If your plan significantly restricts Alecensa access mid-year, you may qualify for a Special Enrollment Period to change plans.

Appeals Process in Virginia

If your renewal is denied, Virginia provides robust appeal options:

Internal Appeals (First Step)

  • Timeline: 65 days from denial notice
  • Expedited option: Available for urgent medical situations
  • Required: Must complete before external review

External Review (Virginia Bureau of Insurance)

After exhausting internal appeals:

  • Timeline: 120 days from final internal denial
  • Process: Independent medical review by board-certified oncologists
  • Cost: Free to Virginia residents
  • Decision timeline: 45 days (72 hours if expedited)

Contact Virginia Bureau of Insurance:

Federal Review (Automatic)

For Medicare Advantage denials, your case automatically advances to CMS's Independent Review Entity (IRE) after internal appeals, providing an additional layer of independent review.

Personal Renewal Tracker

Use this template to stay organized:

Authorization Details:

  • Current expiration date: ___________
  • Renewal start date (45 days prior): ___________
  • Prescribing oncologist: ___________
  • Humana member ID: ___________

Documentation Checklist:

  • Recent imaging (within 60 days)
  • Liver function tests (within 30 days)
  • Oncologist renewal letter
  • Treatment response summary
  • Adverse event documentation

Submission Tracking:

  • Date submitted: ___________
  • Confirmation number: ___________
  • Expected decision date: ___________
  • Decision received: ___________

If Denied:

  • Denial reason: ___________
  • Appeal filed date: ___________
  • External review needed: Y/N

From our advocates: We've seen patients successfully maintain Alecensa coverage by establishing a routine renewal calendar and working closely with their oncology team's prior authorization specialist. The key is treating renewal as an ongoing process rather than a one-time event, with continuous documentation of treatment benefit and tolerance.

Renewing Alecensa coverage requires proactive planning and thorough documentation of ongoing treatment benefit. By starting early, maintaining complete clinical records, and understanding Virginia's appeal options, you can minimize treatment interruptions and ensure continued access to this critical therapy.

Counterforce Health helps patients and clinicians navigate insurance denials by analyzing payer policies and crafting targeted appeals that address specific denial reasons. Their expertise in specialty drug approvals can be particularly valuable when facing complex renewal challenges.

FAQ

How long does Humana take to process Alecensa renewals in Virginia? Standard renewals receive decisions within 72 hours, or 24 hours if expedited review is approved due to medical urgency.

What if my oncologist is out of network with Humana? Out-of-network providers can still submit prior authorization requests, but you may face higher out-of-pocket costs. Consider requesting a single-case agreement for coverage.

Can I appeal if Humana adds new step therapy requirements? Yes, you can request a formulary exception based on medical necessity, previous treatment failures, or contraindications to preferred alternatives.

Does Virginia have special protections for cancer patients? Virginia allows expedited external review for cancer treatment denials without exhausting internal appeals, recognizing the time-sensitive nature of oncology care.

What happens if I switch Humana plans mid-year? Your prior authorization may need to be resubmitted under the new plan's criteria, even if both are Humana products.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with Virginia insurance appeals, contact the State Corporation Commission's Bureau of Insurance.

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