By Counterforce Health Team in Eloctate (coagulation factor VIII, rFVIIIFc; efmoroctocog alfa) —

Resources to Get Eloctate (Coagulation Factor VIII) Approved with Humana in New York: Forms, Portals & Contacts

Answer Box: Getting Eloctate Covered by Humana in New York

Eligibility: Eloctate requires prior authorization through Humana Medicare Advantage plans. Fastest path: Contact your hematologist to submit PA documentation including hemophilia A diagnosis (ICD-10: D66), prior Factor VIII trials, and treatment plan. First step today: Call Humana at 800-867-6601 to verify your plan's formulary status and obtain current PA forms. If denied, you have 65 days to appeal internally, followed by New York's external review process through the Department of Financial Services.

Table of Contents

  1. Start Here: Verify Your Plan Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Network Transfer
  5. Appeals Process and Timelines
  6. New York State External Review
  7. Support Lines and Contacts
  8. Common Denial Reasons and Solutions
  9. Keeping Resources Current

Start Here: Verify Your Plan Coverage

Before beginning the prior authorization process, confirm your specific Humana plan details and Eloctate's formulary status.

Step 1: Identify Your Plan Type

  • Check your insurance card for "Medicare Advantage" or "Part D" designation
  • Verify your county in New York, as formularies vary by region
  • Call Humana member services at 800-867-6601 to confirm plan specifics

Step 2: Check Formulary Status Access Humana's Prior Authorization Search Tool to verify if Eloctate requires:

  • Prior authorization
  • Step therapy (trying other Factor VIII products first)
  • Quantity limits
  • Preferred specialty pharmacy requirements
Note: Eloctate typically requires prior authorization due to its high cost (~$856,000 annually at wholesale acquisition cost) and availability of alternative Factor VIII products.

Required Forms and Documentation

Core Prior Authorization Requirements

Medical Documentation Needed:

  • Confirmed hemophilia A diagnosis with ICD-10 code D66
  • Complete bleeding history and severity assessment
  • Previous Factor VIII products tried and outcomes
  • Current weight and dosing calculations
  • Inhibitor testing results (if applicable)
  • Treatment goals (prophylaxis vs. on-demand)

Provider Requirements:

  • Prescription from qualified hematologist
  • Medical necessity letter addressing:
    • Why Eloctate is preferred over formulary alternatives
    • Previous treatment failures or contraindications
    • Expected clinical outcomes
  • Recent laboratory results and bleeding episode documentation

Forms to Complete

Primary Forms (verify current versions):

  • Humana Prior Authorization Request Form
  • Medicare Part D Coverage Determination Request (if applicable)
  • Physician Attestation Form for medical necessity
Important: Form versions change frequently. Always download the most current forms from the Humana Provider Portal rather than using saved copies.

Submission Portals and Methods

Humana Provider Portal:

  • URL: provider.humana.com
  • Requires provider registration and login
  • Upload supporting documents as PDF attachments
  • Track submission status and receive electronic notifications

Member Portal:

  • Access through Humana member services online
  • Patients can submit formulary exception requests
  • View prior authorization status updates

Alternative Submission Methods

Fax Submission:

  • Use fax numbers provided on current PA forms
  • Include cover sheet with member ID and drug name
  • Confirm receipt by calling Humana within 24 hours

Phone Submission:

  • Provider line: 800-555-CLIN (2546)
  • Available Monday-Friday, 8 AM - 8 PM local time
  • Have all documentation ready before calling

Specialty Pharmacy Network Transfer

Eloctate is typically dispensed through Humana's specialty pharmacy network, primarily CenterWell Specialty Pharmacy.

Transfer Process

Step 1: Initiate Transfer

  • Take photos of current prescription label
  • Contact CenterWell directly or use online transfer portal
  • Provide prescriber information and current pharmacy details

Step 2: Clinical Review

  • CenterWell pharmacists review dosing and administration
  • Coordinate with your hematology team for any adjustments
  • Verify insurance coverage and copay assistance eligibility

Step 3: Delivery Setup

  • Choose delivery location (home, clinic, or infusion center)
  • Schedule regular shipments aligned with dosing schedule
  • Set up temperature-controlled storage and handling
Tip: CenterWell provides comprehensive hemophilia support including injection training, adherence monitoring, and financial assistance program enrollment.

Appeals Process and Timelines

Internal Appeals (First Level)

Timeline: You have 65 days from denial notice to file an internal appeal.

Required Steps:

  1. Complete Humana's Appeal/Redetermination Form
  2. Include original denial letter and member ID
  3. Provide additional medical documentation supporting necessity
  4. Submit via phone (800-867-6601), online portal, or fax

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

Expedited Appeals

When to Request:

  • Immediate treatment needed to prevent serious health consequences
  • Current Factor VIII supply running low with active bleeding risk
  • Hospitalization or emergency care anticipated without treatment

Documentation Required:

  • Physician statement of urgency
  • Recent bleeding episode records
  • Current Factor VIII inventory levels

Timeline: 72 hours for expedited decisions.

New York State External Review

If Humana denies your internal appeal, New York residents may be eligible for external review through the Department of Financial Services (DFS).

Eligibility Verification

Important: Medicare Advantage plans may fall under federal rather than state jurisdiction. Contact DFS at (800) 400-8882 to verify eligibility before filing.

If Eligible:

Submission Methods

Fax: (800) 332-2729
Mail: New York State Department of Financial Services, 99 Washington Avenue, Box 177, Albany NY 12210
Expedited: Fax application and call (888) 990-3991 immediately

Additional New York Resources

Community Health Advocates: (888) 614-5400
Free assistance with insurance appeals and coverage issues for New York residents.

Support Lines and Contacts

Member Support

  • General inquiries: 800-867-6601
  • Puerto Rico members: 866-773-5959
  • Pharmacy questions: Available through main member line
  • Appeals status: Track through online portal or phone

Provider Support

  • Prior authorization: 800-555-CLIN (2546)
  • Professionally administered drugs: 1-866-488-5995
  • Peer-to-peer reviews: Request through provider portal
  • Urgent clinical questions: Use expedited review process

What to Ask When Calling

For Prior Authorization Status:

  • "What specific documentation is still needed?"
  • "What is the expected decision timeline?"
  • "Are there preferred alternative medications?"
  • "Can we schedule a peer-to-peer review?"

For Denials:

  • "What was the specific reason for denial?"
  • "What additional evidence would support approval?"
  • "How do I request an expedited appeal?"
  • "What are my external review options?"

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Non-preferred brand Submit medical necessity letter explaining why alternatives failed/contraindicated Previous treatment records, adverse event documentation
Dosing above limits Provide weight-based calculations and bleeding history Current weight, pharmacokinetic studies, bleed logs
Not prescribed by specialist Transfer care to hematologist Referral documentation, specialist consultation notes
Step therapy not completed Document previous Factor VIII trials Pharmacy records, treatment outcomes, failure reasons
Insufficient medical necessity Strengthen clinical documentation Comprehensive bleeding assessment, quality of life impact

Keeping Resources Current

Healthcare policies and forms change frequently. Here's how to stay updated:

Monthly Checks:

  • Review Humana's Prior Authorization List
  • Verify current form versions on provider portal
  • Check for formulary updates affecting Eloctate

Quarterly Reviews:

  • Confirm specialty pharmacy network changes
  • Update contact information and fax numbers
  • Review New York state regulation changes

Annual Updates:

  • Medicare plan changes during open enrollment
  • New York insurance law modifications
  • Updated clinical guidelines affecting coverage
From Our Advocates: "We've found that maintaining a comprehensive file with all prior authorizations, appeals, and supporting documentation saves significant time when policies change or when switching providers. Keep digital copies of everything, including dated screenshots of online submissions."

For patients and providers navigating complex insurance approvals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify specific coverage criteria and draft point-by-point rebuttals aligned with each payer's requirements. By pulling the right clinical evidence and weaving it into appeals that meet procedural requirements, they help reduce the back-and-forth that often delays access to critical medications like Eloctate.

FAQ

How long does Humana prior authorization take for Eloctate in New York? Standard prior authorization decisions are made within 15 business days. Expedited requests receive decisions within 72 hours if clinical urgency is documented.

What if Eloctate is non-formulary on my Humana plan? You can request a formulary exception by demonstrating medical necessity and why preferred alternatives are inappropriate. This requires additional documentation from your hematologist.

Can I request an expedited appeal if denied? Yes, if waiting for standard appeal timing could seriously harm your health. Document clinical urgency with recent bleeding episodes and physician assessment of risk.

Does step therapy apply if I've used Factor VIII outside New York? Previous treatment history from other states should be documented and submitted as part of your prior authorization. Humana typically recognizes out-of-state treatment records.

What happens if my internal appeal is denied? New York residents may be eligible for external review through the Department of Financial Services, depending on plan type. Medicare Advantage plans may require federal Medicare appeals instead.

How do I transfer my prescription to CenterWell Specialty Pharmacy? Contact CenterWell directly or use their online transfer portal. You'll need photos of your current prescription label and prescriber information.

Are there financial assistance programs for Eloctate? Yes, manufacturer Sobi offers patient assistance programs. CenterWell Specialty Pharmacy can help determine eligibility and complete applications.

What clinical documentation strengthens my prior authorization? Include comprehensive bleeding history, previous Factor VIII treatment outcomes, current inhibitor status, weight-based dosing calculations, and quality of life assessments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently, and individual circumstances vary. Always verify current requirements directly with Humana and consult with your healthcare provider regarding treatment decisions. For additional assistance with insurance appeals in New York, contact Community Health Advocates at (888) 614-5400 or visit the New York Department of Financial Services website.

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