By Counterforce Health Team in Firazyr (icatibant injection) —

The Requirements Checklist to Get Firazyr (icatibant) Covered by Humana in Washington

Answer Box: Getting Firazyr (icatibant) Covered by Humana in Washington

Firazyr requires prior authorization from Humana and is classified as nonpreferred. You have 65 days to appeal denials. Three key steps: 1) Gather HAE diagnosis documentation (ICD-10 code D84.1, C1-INH lab results below 50%), 2) Submit PA request through Humana provider portal with medical necessity letter, 3) If denied, file internal appeal within 65 days, then external review through Washington's IRO process if needed. Start by calling CenterWell Specialty Pharmacy at 1-800-486-2668 to confirm formulary status and initiate prior authorization.

Table of Contents

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

Who Should Use This Checklist

This checklist is designed for Washington residents with Humana Medicare Advantage or Part D plans who need Firazyr (icatibant injection) for hereditary angioedema (HAE) attacks. Use this if you've received a denial, are preparing an initial prior authorization request, or want to prevent common approval delays.

Expected outcome: Following this checklist increases approval likelihood by ensuring all required documentation is complete and properly formatted before submission. Most approvals occur within 7 days when documentation meets Humana's criteria.

Member & Plan Basics

✓ Verify Active Coverage

  • Confirm Humana plan is active and covers prescription drugs
  • Check if you have Medicare Part D or Medicare Advantage with drug coverage
  • Verify your member ID and group number from insurance card

✓ Plan Requirements Check

  • Prior Authorization: Required for all Firazyr prescriptions
  • Formulary Status: Nonpreferred (Tier 4-5 typically)
  • Deductible: May apply before coverage begins
  • Step Therapy: May require trial of generic icatibant first
Note: Generic icatibant is preferred over brand-name Firazyr on most Humana formularies.

Clinical Criteria Requirements

✓ HAE Diagnosis Documentation

  • ICD-10 Code D84.1 documented in medical record
  • Laboratory confirmation with results showing:
    • C1-esterase inhibitor level below 50% of normal
    • C4 complement level below normal range
    • Both antigenic and functional C1-INH measurements

✓ Attack History & Severity

  • Documentation of recurrent HAE attacks (frequency and severity)
  • Emergency department visits or hospitalizations for angioedema
  • Failed response to antihistamines, corticosteroids, or epinephrine
  • Family history of HAE (if applicable)

✓ Treatment History

  • Prior therapy documentation if step therapy applies:
    • Generic icatibant trial results
    • Other HAE treatments tried (C1-INH concentrates, ecallantide)
    • Reasons for treatment failures or intolerances

✓ Dosing & Duration Requirements

  • Maximum dosing: 30 mg per attack, up to 3 doses per 24 hours
  • Quantity limits: Typically 6-12 doses per month approved
  • Self-administration training documented by healthcare provider

Coding & Billing Requirements

✓ Diagnostic Codes

  • Primary ICD-10: D84.1 (Defects in the complement system)
  • Supporting codes for complications if applicable

✓ Billing Codes (For Providers)

  • HCPCS J-Code: J1744 (Injection, icatibant, 1 mg)
  • Billing units: 30 units per 30 mg syringe (not 1 unit)
  • NDC number: Include manufacturer-specific 11-digit NDC
  • Modifiers: JB for subcutaneous administration if required

✓ Place of Service

  • Home administration: Code 12
  • Office-based: Code 11
  • Emergency department: Code 23 (for acute attacks)

Documentation Packet Checklist

✓ Provider Letter of Medical Necessity Must Include:

  • Patient identification: Name, DOB, member ID
  • HAE diagnosis with ICD-10 code D84.1
  • Laboratory results: C1-INH levels, C4 levels, genetic testing (if available)
  • Attack history: Frequency, severity, triggers
  • Prior treatments: What was tried, outcomes, reasons for failures
  • Clinical rationale: Why Firazyr is medically necessary
  • Dosing plan: 30 mg per attack, maximum frequency
  • Self-administration training: Confirmation of patient education

✓ Required Attachments

  • Laboratory reports showing C1-INH deficiency
  • Prescription with diagnosis and quantity requested
  • Prior therapy documentation (if step therapy applies)
  • Emergency records from previous HAE attacks
  • Specialist consultation notes (allergist/immunologist preferred)
Clinician Corner: Include specific C1-INH levels and reference normal ranges. For adults, normal C1-INH levels are 10.2-20.3 mg/dL (males) and 10.3-20.5 mg/dL (females). HAE diagnosis requires levels below 50% of normal.

Submission Process

✓ Prior Authorization Submission

  • Submit through: Humana Provider Portal (primary method)
  • Alternative: Fax to designated PA fax number (verify current number)
  • Required form: Humana Prior Authorization Request form
  • Complete all fields: Missing information causes automatic delays

✓ Specialty Pharmacy Coordination

  • Contact CenterWell Specialty Pharmacy: 1-800-486-2668
  • Verify network status: Confirm pharmacy can dispense Firazyr
  • Coordinate shipment: Arrange temperature-controlled delivery

✓ Timeline Expectations

  • Standard PA decision: 7 calendar days
  • Expedited review: 72 hours (if urgent medical need)
  • Appeal deadline: 65 days from denial notice

Specialty Pharmacy Requirements

✓ Network Verification

  • Confirm CenterWell Specialty can fill prescription
  • Check alternatives if CenterWell cannot fulfill
  • Verify coverage at chosen specialty pharmacy

✓ Transfer Process (if needed)

  • Request transfer from current pharmacy to Humana-preferred vendor
  • Provide prescription details: NDC, quantity, prescriber information
  • Confirm receipt of prescription at new pharmacy

✓ Shipment Coordination

  • Schedule delivery when someone will be home
  • Verify cold storage requirements are met
  • Confirm receipt and inspect medication upon delivery

After Submission: Tracking & Follow-up

✓ Confirmation & Tracking

  • Record confirmation number from PA submission
  • Set calendar reminder to check status in 3-5 days
  • Monitor member portal for decision updates
  • Keep copies of all submitted documents

✓ Status Check Schedule

  • Day 3: Check initial processing status
  • Day 5: Follow up if no response
  • Day 7: Escalate if no decision received
  • Day 8+: Consider expedited appeal if urgent

✓ Document Everything

  • PA request date and confirmation number
  • Contact names and phone numbers
  • Reference numbers for all communications
  • Decision dates and outcomes

Common Denial Prevention Tips

✓ Five Common Pitfalls to Avoid

  1. Incomplete HAE diagnosis documentation
    • Fix: Include both antigenic and functional C1-INH levels below 50%
  2. Missing step therapy documentation
    • Fix: Document generic icatibant trial or medical contraindication
  3. Incorrect billing units
    • Fix: Bill 30 units for 30 mg syringe, not 1 unit
  4. Insufficient attack history
    • Fix: Provide specific dates, severity, and emergency care received
  5. Generic substitution not addressed
    • Fix: Document medical necessity for brand-name Firazyr vs. generic
From our advocates: We've seen cases where providers submitted PA requests without current lab values, leading to automatic denials. Always include C1-INH levels drawn within the past 6 months, as some plans require recent confirmation of deficiency levels.

Printable One-Page Checklist

Before Submission:

□ HAE diagnosis with ICD-10 D84.1
□ C1-INH levels below 50% documented
□ Attack history with frequency/severity
□ Prior therapy trials documented
□ Provider letter of medical necessity complete
□ All required attachments included

Submission:

□ Submit via Humana Provider Portal
□ Contact CenterWell Specialty: 1-800-486-2668
□ Record confirmation number
□ Set 7-day follow-up reminder

If Denied:

□ File appeal within 65 days
□ Include additional clinical documentation
□ Request expedited review if urgent
□ Consider external review in Washington

Appeals Process for Washington

✓ Internal Appeals (First Level)

  • Timeline: 65 days from denial notice
  • Submission: Humana member portal or mail/fax
  • Decision timeframe: 7 days standard, 72 hours expedited
  • Required: Appeal form and supporting documentation

✓ External Review (Washington State)

If internal appeals fail, Washington residents have additional rights:

  • Timeline: 180 days from final internal denial
  • Process: Independent Review Organization (IRO) per RCW 48.43.535
  • Contact: Washington Office of Insurance Commissioner at 1-800-562-6900
  • Decision: 30 days standard, 72 hours expedited
  • Outcome: IRO decision is binding on Humana

✓ Washington State Resources

  • OIC Consumer Advocacy: 1-800-562-6900
  • Appeal templates: Available on OIC website
  • External review request: Submit to OIC or directly to Humana
Tip: Washington's external review process has overturned many specialty drug denials. The IRO includes medical experts who can override plan policies if they're found unreasonable.

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements. For complex cases like HAE medications, we help identify the exact documentation needed and draft point-by-point rebuttals using the right clinical evidence and procedural requirements.

Whether you're navigating Humana's prior authorization process or preparing for an appeal, having the right documentation and following payer-specific workflows significantly improves your chances of approval. Counterforce Health's approach ensures that appeals meet both clinical standards and administrative requirements, reducing the back-and-forth that often delays patient access to critical medications like Firazyr.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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