By Counterforce Health Team in Amvuttra (vutrisiran) —

Resources to Get Amvuttra (vutrisiran) Approved with Humana in Texas: Complete Forms, Portals & Appeal Guide

Answer Box: Getting Amvuttra (vutrisiran) Covered by Humana in Texas

Fastest path to approval: Submit the current Humana Medicare Prior Authorization Form for Amvuttra via Availity Essentials portal or fax to 1-888-447-3430, including genetic confirmation for hATTR-PN or cardiomyopathy documentation for ATTR-CM. If denied, you have 65 days to appeal internally, then can request external review through Texas Department of Insurance. Start today: Verify your plan requires PA by calling 800-555-CLIN (2546) and download the current form from PrescriberPoint.

Table of Contents

  1. Start Here: Verify Your Plan & Policy
  2. Required Forms & Current Versions
  3. Submission Portals & Upload Requirements
  4. Fax & Mail Submission Details
  5. CenterWell Specialty Pharmacy Setup
  6. Support Lines & Contact Directory
  7. Texas Appeals & External Review Process
  8. When to Update Your Resources

Start Here: Verify Your Plan & Policy

Before gathering forms, confirm your specific Humana plan's requirements for Amvuttra (vutrisiran). Not all Humana plans are identical—Medicare Advantage, Medicare Part D, and commercial plans may have different policies.

Quick verification steps:

  1. Call Humana at 800-555-CLIN (2546) with your member ID
  2. Ask specifically: "Does my plan require prior authorization for Amvuttra (vutrisiran)?"
  3. Request the current formulary tier and any step therapy requirements
  4. Confirm whether you need specialty pharmacy enrollment
Note: Amvuttra typically requires prior authorization due to its high cost (~$476,000 annually) and specific clinical indications for hereditary transthyretin-mediated amyloidosis.

Required Forms & Current Versions

Primary Prior Authorization Form

The most current form is the "Humana – Medicare Prior Authorization Form" for Amvuttra, verified current as of June 2025. Access it through:

Exception/Appeal Forms

If Amvuttra is denied or not on formulary:

Form Type Form Name When to Use Download Link
Formulary Exception Request for Medicare Prescription Drug Coverage Determination Drug not on formulary or wrong tier Humana Forms Portal
Internal Appeal Medicare Redetermination Request After initial denial Included with denial notice
Representative Authorization Appointment of Representative Someone filing on your behalf Humana Forms Portal

Medical Necessity Documentation

Your prescriber must include:

  • For hATTR-PN: Genetic testing confirming TTR mutation, neuropathy staging, prior treatment failures
  • For ATTR-CM: Echo/cardiac MRI showing cardiomyopathy, NT-proBNP levels, NYHA functional class
  • For both: ICD-10 codes, contraindications to alternatives, treatment goals

Submission Portals & Upload Requirements

Primary Submission: Availity Essentials

Providers must use Availity Essentials for most Humana submissions:

  • Portal URL: Availity Essentials (verify current link)
  • Account Required: Yes, for registered providers only
  • Upload Capabilities: Labs, diagnostics, clinical notes, PA forms
  • Processing Time: Typically faster than fax submission

What to upload:

  • Completed PA form
  • Clinical notes supporting diagnosis
  • Lab results (genetic testing, cardiac markers)
  • Prior treatment documentation
  • Imaging reports (echo, cardiac MRI for ATTR-CM)

Alternative: CoverMyMeds

For electronic prior authorization (ePA):

  • Platform: CoverMyMeds Humana portal
  • Benefits: Real-time status updates, automated form routing
  • Requirements: Provider account setup

Fax & Mail Submission Details

Fax Numbers by Request Type

Request Type Fax Number Hours Notes
General Pharmacy PA 877-486-2621 24/7 Standard processing
Professionally Administered Drugs 1-888-447-3430 24/7 For Amvuttra injections
CenterWell Specialty Forms 800-379-7617 24/7 Specialty pharmacy specific

Cover Sheet Best Practices

Include on every fax:

  • Patient name and Humana ID
  • Prescriber name and NPI
  • "URGENT: Prior Authorization Request for Amvuttra (vutrisiran)"
  • Total page count
  • Return fax number for questions

Mail Addresses

Physical mail addresses are provided on specific forms. Always use the address printed on the current form version, as these change periodically.

CenterWell Specialty Pharmacy Setup

Humana partners with CenterWell Specialty Pharmacy for Amvuttra distribution:

Enrollment Process

  1. Provider initiates: Call 800-486-2668 after PA approval
  2. Patient enrollment: CenterWell contacts patient within 24-48 hours
  3. Benefits verification: Automatic copay calculation
  4. Delivery scheduling: Quarterly shipments to clinic or patient

Required Information

  • Humana member ID and PA approval number
  • Prescriber information and NPI
  • Preferred delivery address (clinic vs. home)
  • Administration schedule preferences

Contact Information

  • Phone: 800-486-2668 (TTY: 711)
  • Hours: Monday–Friday 8 AM–11 PM, Saturday 8 AM–6:30 PM ET
  • Provider Resources: CenterWell Specialty

Support Lines & Contact Directory

For Providers

Purpose Phone Number Hours Best For
Prior Authorization 800-555-CLIN (2546) Mon–Fri 8 AM–8 PM local General PA questions
Expedited Decisions 866-737-5113 Mon–Sun 8 AM–8 PM ET Urgent cases
Case Management 800-555-CLIN (2546) Mon–Fri 8 AM–8 PM local Complex cases

For Members/Patients

  • General Customer Service: Number on member ID card
  • Appeals & Exceptions: Humana Appeals Portal
  • Pharmacy Benefits: Same as customer service number

Key Questions to Ask

When calling Humana support:

  1. "What's the current status of my Amvuttra prior authorization?"
  2. "Are there any missing documents or requirements?"
  3. "What's the expected decision timeline?"
  4. "If denied, what are my appeal options?"
  5. "Do I need specialty pharmacy enrollment?"

Texas Appeals & External Review Process

Internal Appeals (Required First Step)

Timeline: 65 days from denial notice to file appeal Decision Time:

  • Pre-service: 30 days
  • Post-service: 60 days
  • Part D: 7 days standard, 24 hours expedited

How to File:

  • Use form included with denial notice
  • Submit via Humana Appeals Portal
  • Include medical necessity letter from prescriber

External Review via Texas Department of Insurance

If Humana's internal appeal is denied, Texas residents can request independent review:

Texas Department of Insurance Contact:

External Review Process:

  1. File request within 4 months of final internal denial
  2. TDI assigns Independent Review Organization (IRO)
  3. IRO decision within 20 days (5 days for urgent cases)
  4. IRO decision is binding on Humana
Important: Medicare plans follow federal appeal rules, but Texas residents can still seek assistance from TDI for guidance and complaint filing.

When to Request Expedited Review

Request expedited appeals when:

  • Delay could seriously harm your health
  • You're currently on Amvuttra and facing discontinuation
  • You have progressive symptoms requiring immediate treatment

When to Update Your Resources

Healthcare policies and forms change regularly. Update your resources:

Monthly: Check for new form versions on PrescriberPoint Quarterly: Verify contact numbers and fax lines Annually: Review formulary changes and PA requirements After denials: Confirm you're using the most current appeal forms

Key indicators to check for updates:

  • Form version dates
  • Policy effective dates
  • Contact number changes
  • New submission portal features

Common Denial Reasons & How to Address Them

Denial Reason Required Documentation Where to Find It
Missing genetic testing TTR gene sequencing results Genetics lab report
Insufficient staging Neuropathy assessment scores Neurology notes
No prior treatment trials Documentation of failed alternatives Pharmacy records, clinical notes
Incomplete cardiac evaluation Echo, NT-proBNP, NYHA class Cardiology reports
Wrong diagnosis codes Correct ICD-10 for hATTR or ATTR-CM Clinical coding resources

Clinician Corner: Medical Necessity Letter Essentials

Your medical necessity letter should address:

For hATTR-PN:

  • Genetic confirmation of pathogenic TTR variant
  • Neuropathy staging (PND score, NIS+7)
  • Prior treatment failures or contraindications
  • Progressive symptoms despite current therapy

For ATTR-CM:

  • Imaging evidence of cardiomyopathy
  • Biomarker elevation (NT-proBNP, troponin)
  • Functional limitation (NYHA class)
  • Treatment goals (reduce hospitalizations, improve quality of life)

Supporting Evidence:

  • Reference FDA labeling for approved indications
  • Cite relevant guidelines (Heart Failure Society, European Society of Cardiology)
  • Include dosing rationale and monitoring plan

Patient Assistance & Cost Support

While working through insurance approval, explore additional support:

Alnylam Assist Program:

  • Website: alnylamassist.com (verify current link)
  • Services: Copay assistance, prior authorization support, appeals assistance
  • Eligibility: Varies by insurance type and income

Foundation Support:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)
Tip: Start foundation applications early, as funds are limited and awarded first-come, first-served.

FAQ: Amvuttra Coverage with Humana in Texas

Q: How long does Humana prior authorization take for Amvuttra? A: Standard PA decisions are typically made within 14 days. Expedited requests are decided within 24-72 hours if urgency is documented.

Q: What if Amvuttra isn't on my Humana formulary? A: Request a formulary exception using the Medicare Prescription Drug Coverage Determination form. Include medical necessity documentation explaining why formulary alternatives are inappropriate.

Q: Can I get Amvuttra while my appeal is pending? A: Possibly. If you're currently on Amvuttra, request continuation of benefits during appeal. New patients may qualify for emergency supply in urgent situations.

Q: Does step therapy apply to Amvuttra in Texas? A: This depends on your specific Humana plan. Some plans may require trials of other TTR-targeting therapies first. Check your plan documents or call member services.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by Humana. External appeals in Texas are reviewed by independent organizations contracted through the Texas Department of Insurance, providing an impartial second opinion.

How Counterforce Health Can Help

Navigating prior authorization and appeals for expensive specialty drugs like Amvuttra can be overwhelming. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to your plan's own rules.

For medications like Amvuttra, we pull the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals with required clinical facts including diagnosis codes, prior treatment failures, and dosing rationale. This systematic approach helps patients, clinicians, and specialty pharmacies get prescription drugs approved more efficiently.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and procedures change frequently. Always verify current requirements with Humana and consult with your healthcare provider regarding treatment decisions. For specific legal questions about insurance appeals, consider consulting with a qualified attorney or patient advocate.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.