By Counterforce Health Team in Busulfex (busulfan injection) —

Resources to Get Busulfex (Busulfan Injection) Approved with Humana in New Jersey: Forms, Appeals, and Provider Contacts

Answer Box: Getting Busulfex Covered by Humana in New Jersey

Busulfex (busulfan injection) typically requires prior authorization from Humana as a professionally administered drug under the medical benefit. Start by verifying your plan type (Medicare Advantage vs. commercial) and checking Humana's current prior authorization list. Submit requests through the Humana Provider Portal via Availity or use their professionally administered drug PA form. New Jersey residents have strong appeal rights through both Humana's internal process and the state's Independent Health Care Appeals Program (IHCAP) managed by Maximus Federal Services.

First step today: Call the provider services number on your Humana ID card to confirm PA requirements and obtain the correct submission portal or fax number for your specific plan.

Table of Contents

I. Start Here: Verify Your Plan and Find the Right Forms

Check Your Humana Plan Type

Busulfex coverage requirements vary significantly between Humana products:

Medicare Advantage Plans: Prior authorization typically required for professionally administered chemotherapy drugs. Submit through medical benefit PA process, not Part D pharmacy forms.

Commercial Plans: May require PA depending on your employer's benefit design. Check your Summary of Benefits or call the number on your ID card.

Medicaid Plans: Follow Humana's Medicaid PA requirements, which may differ from commercial or Medicare processes.

Action Step: Look at your Humana ID card. The plan name and member ID format will indicate your product type. Medicare Advantage IDs typically start with "H" followed by numbers.

Confirm Busulfex is on Your Plan's PA List

  1. Visit the Humana Provider Portal and select your plan year
  2. Search for "busulfan," "Busulfex," or HCPCS code "J0594"
  3. Note whether it's listed under "professionally administered drugs" or "chemotherapy agents"

If you can't access the provider portal, call Humana Provider Services to verify PA requirements for your specific plan.

II. Prior Authorization Forms and Requirements

Medical Benefit PA Form (Most Common for Busulfex)

For professionally administered Busulfex, use Humana's medical drug prior authorization form:

Required Information:

  • Patient demographics and Humana ID
  • Prescriber NPI and contact information
  • Diagnosis with ICD-10 codes (e.g., C92.1x for CML)
  • Planned treatment dates and facility
  • Complete conditioning regimen details
  • Prior therapy history and failures
  • Clinical rationale for IV busulfan vs. alternatives

Where to Find: Available through the Humana Provider Portal under "Prior Authorizations – Professionally Administered Drugs"

Coverage Determination Form (Part D Cases Only)

If Busulfex is processed as a Part D specialty drug (rare), use the "Request for Medicare Prescription Drug Coverage Determination" form available from Humana's documents page.

III. Submission Portals and Electronic Options

Primary Electronic Submission

Availity Portal (Preferred Method):

  1. Access through the Humana Provider Portal
  2. Select "Prior Authorization" workflow
  3. Choose appropriate product (Medicare, Commercial, etc.)
  4. Complete medical drug PA request
  5. Upload supporting documentation

Account Requirements: Providers must be registered with Availity and credentialed with Humana. Registration is free but requires verification.

Alternative Electronic Options

CoverMyMeds: Humana accepts electronic PA submissions through CoverMyMeds for some drug categories. Check if Busulfex/J0594 is supported for your plan type.

Note: Electronic submission typically provides faster processing and tracking compared to fax or mail.

IV. Fax Numbers and Mailing Addresses

Medical Benefit Fax Submission

Humana Medication Intake Team: Use the dedicated fax number listed on Humana's professionally administered drug PA page (verify current number as it may change annually).

Part D Fax: 877-486-2621 (only for retail pharmacy benefit cases)

Cover Sheet Best Practices

Include on your fax cover sheet:

  • "URGENT - PRIOR AUTHORIZATION REQUEST"
  • Patient name and Humana ID
  • Drug name: "Busulfex (busulfan injection), J0594"
  • Prescriber name and NPI
  • Expected treatment start date
  • Total page count

Mail Submission

Paper forms should be sent to the address specified on the current PA form. Always use certified mail for important submissions and keep tracking receipts.

V. Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy

Humana's owned specialty pharmacy is CenterWell Specialty Pharmacy. For outpatient Busulfex administration:

Three Ways to Prescribe:

  1. E-prescribe: Select "CenterWell Specialty Pharmacy" in your EHR
  2. Fax: Use CenterWell's provider fax line (number available in Humana provider tools)
  3. Phone: Call CenterWell provider services line

Buy-and-Bill vs. White Bagging

Hospital/Clinic Administration: Most transplant conditioning is buy-and-bill through the facility. Confirm with Humana whether white bagging (specialty pharmacy delivery) is required or optional.

Prior Authorization Alignment: Ensure your PA request specifies the correct dispensing method to avoid coverage issues.

VI. Support Phone Lines and Contact Numbers

Provider Services

Primary Number: Use the provider services number on the back of the patient's Humana ID card. This routes to the correct department based on plan type.

What to Ask For:

  • "Medical drug prior authorization for professionally administered chemotherapy"
  • Busulfex/busulfan injection, HCPCS J0594
  • Transplant conditioning indication

Member Services

For Patients: Call the member services number on your ID card. Ask specifically about:

  • Prior authorization status
  • Appeal rights and deadlines
  • Expedited review options
  • External review eligibility

Peer-to-Peer Review

Request a peer-to-peer discussion with a Humana medical director if your initial PA is denied. This is often the fastest way to resolve clinical disagreements.

VII. New Jersey Appeal Rights and External Review

Humana Internal Appeals

First Level: 60-65 days from denial to file internal appeal Second Level: Available for Medicare Advantage and some commercial plans Expedited Appeals: 72 hours for urgent cases where delay could cause serious harm

New Jersey External Review (IHCAP)

New Jersey's Independent Health Care Appeals Program provides external review for medical necessity denials:

Who Administers: Maximus Federal Services under contract with NJ Department of Banking and Insurance

Eligibility:

  • Fully insured NJ health plans (not self-funded ERISA plans)
  • Medical necessity or experimental/investigational denials
  • Internal appeals completed (with limited exceptions)

Filing Deadline: Up to 180 days from final internal denial for most commercial plans; 60 days for NJ FamilyCare/Medicaid

How to File:

  1. Complete NJ External Appeal Application (available from DOBI website)
  2. Submit online through Maximus IHCAP portal or by mail/fax
  3. Include copy of final denial letter and supporting clinical documentation

Timeline: Standard reviews completed within 45 days; expedited reviews within 48 hours

Cost: No fee for patients; insurers pay all IURO costs

Important: IURO decisions are binding on insurers. If they overturn Humana's denial, coverage must be provided within 10 business days.

VIII. When to Update Your Resources

Annual Updates (January)

  • Prior authorization lists and formularies
  • Phone numbers and fax numbers
  • Portal access requirements
  • Appeals deadlines and procedures

Quarterly Checks

  • Form versions and submission requirements
  • Specialty pharmacy network changes
  • Policy updates for transplant coverage

Before Each Submission

  • Verify current PA requirements for your patient's specific plan
  • Confirm provider portal access and credentials
  • Check for any urgent policy changes or updates
Pro Tip: Bookmark Humana's provider portal and DOBI's IHCAP page for quick access to current forms and contact information.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide detailed clinical rationale linking to FDA indication FDA label excerpt, NCCN guidelines, transplant evaluation
"Alternative therapy available" Document contraindications to TBI or oral busulfan Organ function tests, prior toxicity records
"Experimental/investigational" Cite FDA approval for transplant conditioning FDA approval letter, published protocols
"Incorrect benefit category" Clarify medical vs. pharmacy benefit Facility administration documentation
"Missing prior authorization" Submit complete PA with all required elements Full medical necessity letter with supporting records

Medical Necessity Documentation Checklist

Clinical Information Required

✓ Primary diagnosis with ICD-10 codes (e.g., C92.10 for CML)
✓ Transplant candidacy evaluation from accredited center
✓ Performance status (ECOG/Karnofsky score)
✓ Prior therapy history with dates, responses, and reasons for failure
✓ Conditioning regimen details including doses and monitoring plan
✓ Risk assessment for VOD and other complications

Supporting Documentation

✓ Transplant center evaluation note
✓ Pathology/cytogenetics reports confirming diagnosis
✓ Laboratory results (CBC, comprehensive metabolic panel, liver function)
✓ Organ function assessment (cardiac, pulmonary, renal)
✓ FDA label excerpts supporting busulfan use in conditioning
✓ Institutional protocol or NCCN guideline references

At Counterforce Health, we help patients, clinicians, and specialty pharmacies navigate complex prior authorization processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific approval pathway and draft comprehensive rebuttals aligned with payer requirements.

FAQ: Busulfex Coverage with Humana in New Jersey

Q: How long does Humana prior authorization take in New Jersey?
A: Standard PA decisions typically take up to 15 days for medical benefit drugs. Expedited requests for urgent transplant conditioning can be processed within 72 hours when clinical urgency is documented.

Q: What if Busulfex is non-formulary on my Humana plan?
A: Non-formulary drugs can still be covered through medical necessity exceptions. Submit detailed clinical documentation showing why formulary alternatives are inappropriate or contraindicated.

Q: Can I request an expedited appeal if my transplant is delayed?
A: Yes. Expedited appeals are available when delays could seriously jeopardize health or ability to regain maximum function. Fixed transplant schedules and donor coordination often qualify for expedited review.

Q: Does step therapy apply to transplant conditioning drugs?
A: Step therapy requirements are uncommon for transplant conditioning regimens, but some plans may require documentation of why specific agents are chosen over alternatives like TBI-based conditioning.

Q: What happens if Humana denies coverage after I've already started treatment?
A: File an immediate appeal and request expedited review. New Jersey's external review process can also address retroactive coverage denials for services already provided.

Q: Can my transplant center file appeals on my behalf?
A: Yes. Healthcare providers can file external appeals with patient consent. Most transplant centers have dedicated financial coordinators experienced with insurance appeals processes.

Q: How do I know if my plan is eligible for New Jersey external review?
A: Fully insured plans issued in New Jersey are generally eligible. Self-funded employer plans follow federal ERISA appeal rules instead. Your denial letter should specify which appeal process applies.

Q: What if I need Busulfex urgently and there's no time for prior authorization?
A: Contact Humana immediately to request emergency authorization. Many plans allow retroactive PA for true medical emergencies, especially in transplant situations where delays could be life-threatening.

About Counterforce Health

Counterforce Health specializes in transforming insurance denials into successful appeals through evidence-based advocacy. We help healthcare teams navigate complex prior authorization requirements by analyzing payer policies, identifying denial patterns, and crafting targeted rebuttals that align with each plan's specific approval criteria. Our platform streamlines the appeals process while ensuring all clinical documentation meets regulatory and payer standards.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Humana plan and consult with healthcare providers for medical decisions.

For additional consumer assistance in New Jersey, contact:

  • NJ Department of Banking and Insurance: 1-800-446-7467
  • IHCAP Hotline: 1-888-393-1062
  • Medicare Rights Center: 1-800-333-4114

Sources & Further Reading

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