By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Humana's Coverage Criteria for Eylea and Lucentis in Illinois: What Counts as "Medically Necessary"?

Answer Box: Getting Eylea/Lucentis Covered by Humana in Illinois

Humana requires prior authorization and often step therapy (trying bevacizumab first) for Eylea and Lucentis in Illinois. Your fastest path: 1) Have your eye doctor document your diagnosis with OCT imaging, 2) Try bevacizumab if you haven't already (unless contraindicated), 3) Submit prior authorization with clinical justification. If denied, you have 65 days to appeal and can request external review through Illinois Department of Insurance within 30 days of final denial.

Table of Contents

  1. Humana's Policy Overview
  2. Medical Necessity Requirements
  3. Step Therapy and Exceptions
  4. Quantity Limits and Dosing
  5. Required Diagnostics and Documentation
  6. Appeals Process in Illinois
  7. Common Denial Reasons and Solutions
  8. Cost Assistance Options
  9. FAQ
  10. Sources and Further Reading

Coverage at a Glance

Requirement What It Means Status Source
Prior Authorization Required for both drugs Yes Humana PA List
Step Therapy Try bevacizumab first Usually required Step Therapy List
Formulary Status Eylea preferred, Lucentis nonpreferred Variable by plan Drug Lists
Quantity Limits Matches FDA dosing schedules Yes Coverage policies
OCT/Imaging Required for wet AMD, DME Yes Clinical documentation
Appeals Deadline 65 days from denial Strict Medicare Appeals

Policy Overview

Humana applies consistent prior authorization requirements across its Medicare Advantage plans in Illinois for anti-VEGF injections like Eylea (aflibercept) and Lucentis (ranibizumab). These drugs treat wet age-related macular degeneration (AMD), diabetic macular edema, and diabetic retinopathy—conditions that can cause vision loss without prompt treatment.

Plan Types Affected:

  • Medicare Advantage (Part C) plans
  • Medicare Part B coverage for physician-administered drugs
  • Some commercial plans (check your specific formulary)

The key policy documents you'll need are Humana's Prior Authorization List and Step Therapy Preferred Drug List, which are updated annually.

Medical Necessity Requirements

Humana defines medical necessity for Eylea and Lucentis based on FDA-approved indications and clinical evidence. Your doctor must document:

Required Diagnosis Documentation:

  • Confirmed wet AMD, diabetic macular edema, or diabetic retinopathy
  • ICD-10 codes (verify with current coding)
  • Visual acuity measurements
  • OCT (optical coherence tomography) showing retinal fluid or thickening
  • Fluorescein angiography if clinically indicated

Clinical Justification Must Include:

  • Disease severity and impact on vision
  • Treatment goals and expected outcomes
  • Monitoring plan for response and safety
  • Contraindications to preferred alternatives
Clinician Corner: Your medical necessity letter should follow this structure: patient presentation and diagnosis, prior treatments attempted (including bevacizumab if applicable), clinical rationale for the specific anti-VEGF agent, dosing plan based on FDA labeling, and monitoring schedule. Include recent OCT images and visual acuity measurements.

Step Therapy and Exceptions

Step Therapy Requirement: Humana typically requires patients to try bevacizumab (Avastin) before approving Eylea or Lucentis, unless you have a documented medical exception or are already established on therapy.

Automatic Exemptions:

  • Patients with paid claims for Eylea/Lucentis in the past year
  • Medical contraindications to bevacizumab
  • Prior documented failure or intolerance to bevacizumab

Medical Exception Criteria:

  • Allergy or hypersensitivity to bevacizumab
  • Previous treatment failure with adequate trial
  • Specific clinical factors requiring brand-name therapy
  • Provider attestation of medical necessity

To request an exception, your doctor submits documentation through Humana's provider portal or by fax with supporting clinical records.

Quantity Limits and Dosing

Humana applies quantity limits that align with FDA-approved dosing schedules:

Eylea (Aflibercept):

  • Loading phase: 2 mg every 4 weeks for first 12 weeks
  • Maintenance: 2 mg every 8 weeks (may extend to 16 weeks based on response)

Lucentis (Ranibizumab):

  • Standard dosing: 0.5 mg monthly
  • May be individualized based on clinical response

Exceeding Limits: If your condition requires more frequent injections, your doctor must provide clinical justification and document inadequate response to standard dosing intervals. This requires detailed progress notes and imaging showing persistent or worsening disease activity.

Required Diagnostics and Documentation

Essential Clinical Documentation:

  • Recent OCT showing retinal pathology (within 30 days of request)
  • Visual acuity testing (Snellen or ETDRS)
  • Fundus photography documenting retinal changes
  • Fluorescein angiography (if clinically indicated)

Prior Treatment History:

  • Documentation of previous anti-VEGF therapy attempts
  • Response to prior treatments
  • Reasons for discontinuation or switching
  • Adverse reactions or intolerances

Ongoing Monitoring Requirements:

  • Regular OCT imaging to assess response
  • Visual acuity measurements at each visit
  • Intraocular pressure monitoring
  • Documentation of treatment response and any complications

Appeals Process in Illinois

If Humana denies your prior authorization, Illinois residents have robust appeal rights with specific timelines:

Level 1: Internal Appeal (Reconsideration)

  • Deadline: 65 days from denial notice
  • Timeline: Humana has 30 days for pre-service decisions, 7 days for Part B drugs
  • Expedited: 72 hours if delay could jeopardize health
  • How to file: Humana member services or provider portal

Level 2: External Review

  • When: After internal appeal denial
  • Timeline: Same as Level 1 processing times
  • Independent Review Entity (IRE): External medical reviewer

Illinois External Review

  • Deadline: 30 days after final internal denial (shorter than many states)
  • Process: Illinois Department of Insurance coordinates independent physician review
  • Timeline: Decision within 5 business days after IRE receives all materials
  • Cost: Free to consumers
Important: Illinois' 30-day deadline for external review is stricter than the federal 4-month window, so act quickly after receiving a final denial.

Further Escalation:

  • Office of Medicare Hearings and Appeals (OMHA) within 60 days
  • Medicare Appeals Council
  • Federal court (for amounts over $1,760 in 2025)

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document bevacizumab trial or contraindication Prior auth forms, clinical notes, allergy documentation
Insufficient medical necessity Provide detailed clinical justification OCT images, visual acuity, treatment history
Quantity limit exceeded Justify increased frequency Progress notes showing inadequate response to standard dosing
Missing diagnostic imaging Submit required OCT/FA results Recent imaging reports within 30 days
Non-formulary status Request formulary exception Medical necessity letter, prior treatment failures

Scripts for Common Situations:

Patient calling Humana: "I'm calling about my prior authorization denial for [Eylea/Lucentis]. My reference number is [X]. My doctor says this medication is medically necessary for my [condition]. I'd like to understand the specific reason for denial and how to appeal."

Clinic requesting peer-to-peer: "I'm requesting a peer-to-peer review for [patient name], DOB [X], member ID [X]. The denial was for [drug] for [indication]. I have clinical documentation supporting medical necessity and would like to discuss this with your medical director."

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed rebuttals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes.

Cost Assistance Options

Manufacturer Programs:

Illinois-Specific Resources:

  • Illinois Department on Aging pharmaceutical assistance programs
  • Community health centers with sliding fee scales
  • Hospital charity care programs

Medicare Extra Help:

  • Low Income Subsidy (LIS) for Part D costs
  • Medicare Savings Programs through Illinois Department of Healthcare and Family Services

FAQ

How long does Humana prior authorization take in Illinois? Standard requests: 30 days for pre-service, 7 days for Part B drugs. Expedited requests: 72 hours if delay could harm your health.

What if Eylea or Lucentis is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Your doctor must show why formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if waiting could seriously jeopardize your health. Your doctor must attest to the urgency and submit clinical documentation supporting the need for fast review.

Does step therapy apply if I've been on Eylea/Lucentis before? No, if you have paid claims in the past year (or 108 days, depending on plan). Established therapy typically continues without step therapy requirements.

What's the difference between internal and external appeals? Internal appeals are reviewed by Humana. External appeals go to independent medical reviewers who aren't employed by your insurance company.

How do I get help with the appeals process? Contact the Illinois Department of Insurance at 877-527-9431 or the Illinois Attorney General's Health Care Bureau at 877-305-5145.

When to Escalate

Contact Illinois regulators if:

  • Humana doesn't respond within required timeframes
  • You believe the denial violates Illinois insurance law
  • You need help navigating the external review process

Illinois Department of Insurance Office of Consumer Health Insurance:

Illinois Attorney General Health Care Helpline:

  • Phone: 877-305-5145
  • Assists with insurance problems and can intervene informally
From our advocates: We've seen cases where patients successfully overturned Humana denials by providing comprehensive OCT documentation and detailed treatment histories. The key is thorough clinical documentation—don't assume the insurance company has all your medical records. One patient's appeal succeeded after their retinal specialist submitted a detailed letter explaining why bevacizumab was contraindicated due to a previous severe inflammatory reaction.

For complex cases involving multiple denials or unusual clinical circumstances, Counterforce Health can help analyze your specific situation and draft targeted appeals that address Humana's coverage criteria point by point.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by plan and change over time. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For official Illinois insurance regulations and consumer assistance, contact the Illinois Department of Insurance.

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