By Counterforce Health Team in Jaypirca (pirtobrutinib) —

The Complete Requirements Checklist to Get Jaypirca (Pirtobrutinib) Covered by Humana in New York

Answer Box: Your Fastest Path to Approval

Eligibility: Adults with relapsed/refractory mantle cell lymphoma or CLL/SLL after prior BTK inhibitor therapy covered by Humana Medicare Advantage or commercial plans in New York.

Fastest approval path: 1) Verify prior authorization requirement using Humana's PA search tool, 2) Submit complete clinical documentation showing BTK inhibitor failure through CenterWell Specialty Pharmacy or Humana's electronic PA portal, 3) Include manufacturer's Letter of Medical Necessity template.

Start today: Call your oncologist to request enrollment in Lilly Oncology Support Center for benefits verification and interim access if coverage is delayed.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking & Follow-up
  9. Denial Prevention Tips
  10. New York Appeals Process
  11. Printable One-Page Checklist

Who Should Use This Checklist

This comprehensive checklist is designed for patients, caregivers, and healthcare providers seeking Humana coverage for Jaypirca (pirtobrutinib) in New York. You'll need this if you have:

  • Relapsed/refractory mantle cell lymphoma after ≥2 prior systemic therapies including a BTK inhibitor
  • Chronic lymphocytic leukemia or small lymphocytic lymphoma after ≥2 prior therapies including both a BTK inhibitor and BCL-2 inhibitor
  • Active Humana coverage (Medicare Advantage, Part D, or commercial plans)

Expected outcome: Following this checklist typically results in approval within 7-30 days for standard requests, or 24-72 hours for expedited reviews when clinical urgency is documented.

Member & Plan Basics

Coverage Requirements Table

Requirement What It Means Where to Find It Source
Active enrollment Current Humana coverage Member ID card, portal Humana Member Services
Prior authorization PA required for all Jaypirca requests PA search tool Humana PA Search
Specialty pharmacy Must use network specialty pharmacy Pharmacy finder Humana Specialty Rx
Annual renewal PA expires after 12 months Policy documentation Humana PA Policies
Note: Medicare beneficiaries cannot use manufacturer copay cards but may qualify for free drug programs through Lilly's Interim Access Program.

Plan Type Verification

For Medicare Advantage/Part D members:

  • Use federal Medicare appeals process only
  • 65-day internal appeal deadline from denial
  • 7-day standard determination for Part D drugs

For Commercial/ACA plans (NY-regulated):

  • New York State external appeal rights apply
  • 4-month deadline for DFS external appeal after final internal denial
  • Expedited appeals available for urgent cases

Clinical Criteria Requirements

FDA-Approved Indications

Humana's current Jaypirca policy requires documentation matching these exact FDA indications:

Mantle Cell Lymphoma:

  • Adults with relapsed or refractory MCL
  • After ≥2 prior lines of systemic therapy
  • Must include prior BTK inhibitor exposure

CLL/SLL:

  • Adults with CLL or SLL
  • After ≥2 prior lines of therapy
  • Must include both BTK inhibitor AND BCL-2 inhibitor

Required Documentation Elements

✅ Pathology confirmation of MCL, CLL, or SLL with ICD-10 codes ✅ Disease staging and current burden assessment ✅ Complete treatment history with dates, responses, and failure reasons ✅ Prior BTK inhibitor details: drug name, duration, best response, reason for discontinuation ✅ BCL-2 inhibitor history (CLL/SLL only): venetoclax or equivalent exposure ✅ Performance status and current clinical condition ✅ Contraindications to alternative therapies

Clinician Tip: Document specific progression dates and imaging results when BTK inhibitor therapy failed. Phrases like "radiographic progression per Lugano criteria" strengthen medical necessity.

Coding & Billing Requirements

ICD-10 Diagnosis Codes

Mantle Cell Lymphoma (C83.1-):

  • C83.10 - Unspecified site
  • C83.13 - Intra-abdominal lymph nodes
  • C83.18 - Multiple sites
  • C83.19 - Extranodal and solid organ sites

CLL/SLL:

  • C91.10 - Chronic lymphocytic leukemia of B-cell type, not having achieved remission
  • C83.00-C83.09 - Small cell B-cell lymphoma (various sites)

HCPCS and NDC Information

For medical benefit billing:

  • HCPCS: J9399 (Not otherwise classified, antineoplastic drug, oral)
  • Include drug name, strength, and NDC in claim narrative

For pharmacy benefit (typical):

  • Bill using specific NDC for dispensed strength
  • Standard dose: 200 mg orally once daily
  • Available strengths: 50 mg and 100 mg tablets

Documentation Packet Essentials

Core Clinical Documents

  1. Oncology consultation note with complete treatment history
  2. Pathology report confirming lymphoma subtype
  3. Staging workup (CT/PET scans, bone marrow biopsy if applicable)
  4. Prior therapy records showing BTK inhibitor and BCL-2 inhibitor exposure
  5. Current labs (CBC, CMP, performance status assessment)

Letter of Medical Necessity Components

Use Lilly's official LMN template and include:

  • Patient demographics and insurance information
  • Specific diagnosis with ICD-10 code
  • Detailed prior treatment history emphasizing BTK inhibitor failure
  • Clinical rationale for Jaypirca over alternatives
  • Dosing plan and monitoring schedule
  • Prescriber credentials and contact information
From our advocates: We've seen approval rates improve significantly when providers include specific dates of disease progression and quantify tumor burden changes. A composite case showed that documenting "50% increase in lymphadenopathy within 3 months of BTK inhibitor initiation" led to same-day expedited approval.

Submission Process

Electronic Submission (Preferred)

Humana prioritizes electronic PA requests with 95% decided within 1 business day by 2026.

Steps:

  1. Access Humana provider portal
  2. Select "Part D Prior Authorization" for Medicare members
  3. Complete all required clinical fields
  4. Upload supporting documentation as PDFs
  5. Submit and retain confirmation number

Alternative Submission Methods

Fax submission:

  • Use plan-specific PA form
  • Include cover sheet with member ID and prescriber NPI
  • Fax to number listed on member's ID card

Required fields that commonly cause rejections:

  • Incomplete prior therapy dates
  • Missing BTK inhibitor failure documentation
  • Absent prescriber NPI or credentials
  • Unclear diagnosis coding

Specialty Pharmacy Routing

Preferred Humana Network

CenterWell Specialty Pharmacy is Humana's preferred mail-order pharmacy offering:

  • Lower member cost-sharing
  • Integrated PA processing
  • Clinical monitoring services
  • Direct coordination with Humana coverage decisions

Lilly's Contracted Network

Jaypirca is available through two oncology-focused specialty pharmacies:

  • Biologics Specialty Pharmacy
  • Onco360 Specialty Pharmacy

Shipment Verification Steps

  1. Benefits investigation through Lilly Oncology Support Center
  2. PA approval confirmation before first shipment
  3. Patient contact for address, insurance, and delivery preferences
  4. Ongoing refill coordination with automatic prescription transfers

After Submission: Tracking & Follow-up

Timeline Expectations

Submission Type Standard Decision Expedited Decision Source
Electronic PA 1 business day 24-72 hours Humana PA commitments
Fax/Mail PA 7-14 days 72 hours Medicare Part D rules

Status Tracking

What to record:

  • PA confirmation number
  • Submission date and method
  • Expected decision date
  • Follow-up contact scheduled
  • Interim access program enrollment (if applicable)

Check status via:

  • Humana provider portal
  • Member services phone line
  • Specialty pharmacy coordination team

Denial Prevention Tips

Five Common Pitfalls and Solutions

  1. Insufficient prior therapy documentation
    • Fix: Include specific drug names, doses, dates, and documented progression or intolerance
  2. Missing BTK inhibitor failure evidence
    • Fix: Attach clinic notes showing radiographic progression or severe adverse events requiring discontinuation
  3. Incomplete BCL-2 inhibitor history (CLL/SLL)
    • Fix: Document venetoclax or equivalent exposure with response and failure details
  4. Generic medical necessity language
    • Fix: Use specific clinical data points and reference FDA labeling directly
  5. Wrong submission pathway
    • Fix: Verify Medicare vs. commercial plan type and use appropriate forms and deadlines
Tip: Counterforce Health helps patients and providers turn insurance denials into targeted appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned to each plan's specific requirements.

New York Appeals Process

For Humana Commercial Plans (NY-regulated)

Internal Appeal (Required First):

  • Deadline: 65 days from denial notice
  • Submit via Humana member portal or fax
  • Include additional clinical evidence

External Appeal (NY DFS):

For Medicare Advantage/Part D

Federal Medicare Appeals Process:

  • Level 1: Humana reconsideration (60 days to file, 7 days for decision)
  • Level 2: Independent Review Entity
  • Contact: Humana Medicare Appeals

Getting Help

Community Health Advocates provides free assistance to New Yorkers:

Printable One-Page Checklist

Before You Start

☐ Verify active Humana coverage ☐ Confirm PA requirement using search tool ☐ Gather insurance card and member ID ☐ Collect complete treatment history records

Clinical Documentation

☐ Pathology report confirming MCL, CLL, or SLL ☐ ICD-10 diagnosis code documented ☐ ≥2 prior therapy lines documented with dates ☐ BTK inhibitor failure clearly described ☐ BCL-2 inhibitor exposure (CLL/SLL only) ☐ Current staging and disease burden assessment

Submission Package

☐ Completed PA form (plan-specific) ☐ Letter of Medical Necessity using Lilly template ☐ Oncology consultation notes ☐ Prior therapy records with failure documentation ☐ Current labs and imaging reports ☐ Prescriber credentials and NPI

After Submission

☐ Record confirmation number ☐ Schedule follow-up in 7-14 days ☐ Enroll in Lilly Interim Access Program if needed ☐ Contact specialty pharmacy for shipment coordination

Sources & Further Reading

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals that meet each payer's specific requirements. Learn more about our coverage support services.

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For official appeals assistance in New York, contact the Department of Financial Services or Community Health Advocates.

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