By Counterforce Health Team in Dupixent (dupilumab) —

The Requirements Checklist to Get Dupixent (dupilumab) Covered by Humana in Illinois

Answer Box: Your Path to Dupixent (dupilumab) Coverage

Dupixent (dupilumab) requires prior authorization from Humana in Illinois, typically placed on Tier 4 (specialty tier) with 25-33% coinsurance. Submit PA through Humana's provider portal with diagnosis codes, severity documentation, and proof of step therapy failures (topical treatments for atopic dermatitis, inhaled corticosteroids for asthma). Standard review takes 14-30 days; expedited available in 72 hours for urgent cases. If denied, you have 65 days to file internal appeal, then Illinois external review within 30 days of final denial.

First step today: Have your doctor submit prior authorization via Humana's provider portal with complete clinical documentation.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Documentation
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Avoid Them
  10. Appeals Process in Illinois
  11. Printable Checklist

Who Should Use This Checklist

This guide is designed for Humana members in Illinois and their healthcare providers seeking coverage for Dupixent (dupilumab). Use this checklist if you have:

  • Atopic dermatitis (moderate-to-severe, age 6 months and older)
  • Asthma (moderate-to-severe eosinophilic or oral corticosteroid-dependent, age 6 and older)
  • Chronic rhinosinusitis with nasal polyps (adults)
  • Prurigo nodularis (adults)
  • Eosinophilic esophagitis (adults and pediatric patients ≥1 year, weighing ≥15 kg)

Expected outcome: With complete documentation following this checklist, approval rates typically exceed 80% for medically appropriate cases. Appeals succeed in approximately 81.7% of cases when proper evidence is submitted.

Member & Plan Basics

Coverage Verification Requirements

Requirement What to Check Where to Find It
Active Coverage Current enrollment status Humana member portal
Plan Type Medicare Advantage, Part D, Commercial Member ID card
Formulary Status Tier placement, PA required Humana Drug List
Deductible Status Amount met toward annual deductible Member portal or EOB
Specialty Pharmacy Network requirements CenterWell Specialty Pharmacy
Note: Humana typically places Dupixent on Tier 4 (specialty tier), requiring 25-33% coinsurance after deductible is met.

Clinical Criteria Requirements

Indication-Specific Requirements

Atopic Dermatitis:

  • ICD-10: L20.9 (Atopic dermatitis, unspecified)
  • Moderate-to-severe disease (EASI ≥16 or IGA ≥3)
  • Failed topical corticosteroids or calcineurin inhibitors
  • Documentation of quality of life impact

Asthma:

  • ICD-10: J45.9 (Asthma, unspecified)
  • Eosinophilic phenotype OR oral corticosteroid-dependent
  • Failed inhaled corticosteroids + long-acting beta-agonists
  • FEV1 ≤80% predicted with reversibility

Chronic Rhinosinusitis with Nasal Polyps:

  • ICD-10: J33.9 (Nasal polyp, unspecified)
  • Failed intranasal corticosteroids
  • May require failed systemic corticosteroids

Step Therapy Documentation

Humana requires proof of failure, intolerance, or contraindication to:

  1. First-line treatments specific to your condition
  2. Specific medications, doses, and durations (not just "inadequate response")
  3. Clinical outcomes and reasons for discontinuation
  4. Contraindications to required step therapy (if applicable)

Coding and Documentation

Essential Diagnosis Codes

Condition Primary ICD-10 Additional Codes
Atopic Dermatitis L20.9 L20.82 (flexural), L20.84 (intrinsic)
Asthma J45.9 J45.0 (allergic), J45.1 (non-allergic)
CRSwNP J33.9 J32.9 (chronic sinusitis)
Prurigo Nodularis L28.1 -
Eosinophilic Esophagitis K20.0 -

HCPCS/NDC Information

  • HCPCS Code: J3590 (unclassified biologics)
  • NDC Numbers: Verify current NDC with CenterWell Specialty Pharmacy
  • Units: Based on prescribed dose (200mg or 300mg syringes)

Documentation Packet Essentials

Medical Necessity Letter Components

Your physician's letter must include:

  1. Patient demographics and insurance information
  2. Confirmed diagnosis with ICD-10 code
  3. Disease severity with objective measures (EASI, IGA, FEV1, etc.)
  4. Prior treatment history with specific details:
    • Medication names, doses, durations
    • Clinical response and reasons for discontinuation
    • Adverse effects or contraindications
  5. Clinical rationale for Dupixent over alternatives
  6. Treatment goals and monitoring plan
  7. Physician signature and credentials

Required Attachments

  • Chart notes documenting diagnosis and severity
  • Laboratory results (eosinophil count, IgE levels if relevant)
  • Imaging studies (CT scans for CRSwNP)
  • Specialist consultation notes
  • Photography (for atopic dermatitis lesions)
  • Pulmonary function tests (for asthma)
From our advocates: We've seen cases where appeals succeeded simply by adding specific EASI scores and exact dates of topical therapy trials. The more detailed your documentation, the stronger your case becomes.

Submission Process

How to Submit Prior Authorization

Preferred Method: Humana Provider Portal

  • Fastest processing (14-21 days standard)
  • Electronic tracking available
  • Automatic confirmation

Alternative Methods:

  • Fax: 877-486-2621
  • Phone: Contact Humana Clinical Pharmacy Review

Required Form Fields

Ensure completion of:

  • Patient demographics and member ID
  • Prescriber information and NPI
  • Diagnosis codes and clinical justification
  • Prior therapy documentation
  • Requested medication details (strength, quantity, duration)

Specialty Pharmacy Requirements

Humana's Preferred Network

Primary Option: CenterWell Specialty Pharmacy

  • Phone: 844-486-2668 (Illinois DSNP members)
  • Hours: Mon-Fri 8am-8pm, Sat 8am-6pm CT
  • Services: PA assistance, clinical support, financial counseling

Transfer Process

  1. Contact current pharmacy to initiate transfer
  2. Call CenterWell at 844-486-2668 with prescription details
  3. Provide insurance information and prior authorization status
  4. Register online at CenterWellPharmacy.com for tracking
  5. Confirm delivery address and preferred delivery schedule

After Submission: What to Expect

Timeline Expectations

Review Type Processing Time When Available
Standard PA 14-30 days Non-urgent cases
Expedited PA 72 hours Life/health jeopardy
Peer-to-Peer 24-48 hours After initial review

Status Tracking

  • Confirmation number: Record for all submissions
  • Status checks: Weekly via provider portal or phone
  • Documentation: Save all correspondence and reference numbers

Common Denial Reasons & How to Avoid Them

Denial Reason How to Prevent Documentation Needed
Insufficient diagnosis documentation Include severity scores and objective measures EASI ≥16, IGA ≥3, FEV1 results
Missing step therapy Document specific failed treatments Drug names, doses, durations, outcomes
Lack of specialist involvement Include dermatology/pulmonology consultation Specialist notes and recommendations
Inadequate clinical rationale Explain why Dupixent is necessary Comparison to alternatives, guidelines
Incomplete prior authorization form Double-check all required fields Member ID, NPI, diagnosis codes

Appeals Process in Illinois

Internal Appeal Timeline

Deadline: 65 days from denial notice date Decision Time:

  • Standard: 7 calendar days
  • Expedited: 72 hours (with physician urgency statement)

Filing Your Appeal

Submit to: Humana Grievances and Appeals Address: P.O. Box 14546, Lexington, KY 40512-4546 Online: Via Humana member portal

Required Elements:

  • Member information and denial details
  • Medical necessity justification
  • Clinical documentation
  • Specific coverage request

Illinois External Review

If Humana denies your internal appeal, Illinois law provides external review rights:

Deadline: 30 days from final adverse determination Process: Independent Review Organization (IRO) review Timeline: Decision within 5 business days of complete submission Cost: Free to consumers Authority: Illinois Department of Insurance

Contact for Help:

  • Illinois Department of Insurance: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145

Printable Checklist

Pre-Submission Checklist ✓

Patient Information:

  • Active Humana coverage verified
  • Member ID and group number available
  • Specialty pharmacy enrollment initiated

Clinical Documentation:

  • Confirmed diagnosis with ICD-10 code
  • Severity documentation (EASI, IGA, FEV1, etc.)
  • Complete prior therapy history with outcomes
  • Medical necessity letter signed by physician

Required Attachments:

  • Chart notes documenting diagnosis
  • Laboratory results (if applicable)
  • Specialist consultation notes
  • Photography or imaging (condition-specific)

Submission:

  • Prior authorization form completed
  • Submitted via preferred method (provider portal)
  • Confirmation number recorded
  • Follow-up scheduled

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and operational details to strengthen your case.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and plan specifics. Always consult your healthcare provider and insurance plan documents for personalized guidance. For additional help with appeals in Illinois, contact the Illinois Department of Insurance at 877-527-9431.

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