By Counterforce Health Team in Idelvion (albutrepenonacog alfa; rFIX-FP) —

The Requirements Checklist to Get Idelvion (albutrepenonacog alfa) Covered by Humana in Georgia: Prior Authorization, Appeals, and Coding Guide

Answer Box: Getting Idelvion Covered by Humana in Georgia

Who qualifies: Patients with confirmed hemophilia B (Factor IX deficiency <40%) needing prophylaxis, on-demand treatment, or perioperative management. Fastest path: Submit prior authorization through Humana's provider portal with complete clinical documentation including Factor IX levels, inhibitor status, and medical necessity letter. First step today: Gather lab results confirming Factor IX deficiency, prior treatment records, and have your prescriber prepare documentation. If denied, you have 65 days for internal appeal and 60 days for Georgia's external review through the Georgia Department of Insurance.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking Your Request
  9. Common Denial Reasons & How to Avoid Them
  10. Appeals Process in Georgia
  11. Quick Reference Checklist

Who Should Use This Checklist

This guide is designed for:

  • Patients with hemophilia B seeking Idelvion coverage through Humana in Georgia
  • Clinicians and specialty pharmacies submitting prior authorization requests
  • Caregivers navigating insurance approval for factor replacement therapy

Expected outcome: With complete documentation following this checklist, most medically appropriate Idelvion requests receive approval within 30 days. For denials, Georgia's external review process provides a second chance with independent medical experts.

Member & Plan Basics

Coverage Verification

  • Active Humana coverage (Medicare Advantage, commercial, or employer plan)
  • Specialty drug benefit included in your plan
  • Deductible status - verify if met for the plan year
  • Prior authorization requirement - Idelvion typically requires PA for all Humana plans
Tip: Call the member services number on your insurance card to confirm specialty drug coverage and current deductible status before starting the PA process.

Plan Type Considerations

  • Medicare Advantage: Standard 30-day PA timeline, expedited 72-hour option for urgent cases
  • Commercial plans: May have different timelines - verify with your specific plan documents
  • Employer plans: Some have modified formularies - check your Summary of Benefits

Clinical Criteria Requirements

Primary Indication

Idelvion is FDA-approved for hemophilia B patients for:

  • On-demand treatment of bleeding episodes
  • Perioperative management
  • Routine prophylaxis to reduce bleeding frequency

Laboratory Requirements

Test Required Acceptable Values Purpose
Factor IX activity <40% of normal (severe: <1%, moderate: 1-5%, mild: 6-40%) Confirms hemophilia B diagnosis
Inhibitor testing Bethesda assay results Rules out neutralizing antibodies
Complete blood count Recent results within 6 months Baseline hematologic status

Step Therapy Considerations

Humana may require trial of:

  • Standard half-life Factor IX products first
  • Documentation of inadequate response or contraindications to preferred agents
  • Specific medical reasons for extended half-life product (e.g., poor venous access, lifestyle factors)

Coding Requirements

HCPCS J-Code and NDC Numbers

  • Primary code: J7202 (Injection, factor IX, albumin fusion protein, recombinant, Idelvion, 1 IU)
  • Billing unit: Per International Unit (IU) administered

NDC Numbers by Strength:

Strength 11-Digit NDC Billing Format
250 IU 69911-0864-02 N469911086402
500 IU 69911-0865-02 N469911086502
1000 IU 69911-0866-02 N469911086602
2000 IU 69911-0867-02 N469911086702
3500 IU 69911-0869-02 N469911086902

Diagnosis Codes

  • Primary: D67 (Hereditary factor IX deficiency, hemophilia B)
  • Supporting: Z79.899 (Other long-term drug therapy) for prophylaxis

Dosing Calculation

Formula: Weight (kg) × desired Factor IX increase (%) × 1.3 = IU required

Example: 70 kg patient needing 50% increase = 70 × 50 × 1.3 = 4,550 IU

Billing Modifiers

  • JW modifier: For drug amount discarded/wasted
  • JZ modifier: When zero drug was discarded (required by some payers)

Documentation Packet

Provider Note Elements

Your prescriber's clinical note should include:

  • Confirmed diagnosis of hemophilia B with specific Factor IX level
  • Severity classification (severe, moderate, or mild)
  • Current bleeding pattern and impact on quality of life
  • Prior factor treatments tried and outcomes
  • Reason for Idelvion specifically (extended half-life benefits, dosing convenience)
  • Proposed dosing regimen and monitoring plan

Medical Necessity Letter Components

A strong letter of medical necessity should address:

  1. Patient-specific factors requiring extended half-life product
  2. Clinical evidence supporting Idelvion over alternatives
  3. Treatment goals and expected outcomes
  4. Safety considerations and monitoring plan
  5. References to FDA labeling and clinical guidelines

Required Attachments

  • Recent laboratory results (Factor IX level, inhibitor screen)
  • Specialty hematologist consultation notes
  • Previous treatment records and responses
  • Quality of life assessments or bleeding logs (if available)

Submission Process

Humana Prior Authorization Submission

  • Preferred method: Humana provider portal (electronic submission)
  • Alternative: Fax to provider services (verify current fax number with Humana)
  • Timeline: Submit complete request to avoid delays

Required Fields That Commonly Cause Rejections

  • Complete member information (ID number, date of birth, contact information)
  • Prescriber NPI and DEA numbers
  • Specific strength and NDC for Idelvion requested
  • ICD-10 diagnosis code (D67)
  • Clinical justification in provider notes section
Note: Incomplete submissions are the leading cause of PA delays. Double-check all required fields before submitting.

Specialty Pharmacy Routing

Humana's Preferred Network

CenterWell Specialty Pharmacy (formerly Humana Specialty Pharmacy) is Humana's preferred specialty pharmacy for Idelvion in Georgia.

  • Phone: 800-486-2668 (TTY: 711)
  • Hours: Mon-Fri 8am-11pm, Sat 8am-6:30pm ET
  • Registration: Create account through MyHumana portal or call directly

Transfer Process

  1. Prescriber sends prescription to CenterWell via e-prescribe or fax
  2. CenterWell coordinates prior authorization with Humana
  3. Patient enrollment in clinical support programs
  4. Home delivery arranged throughout Georgia
  5. Clinical monitoring and refill management
Important: Using out-of-network specialty pharmacies may result in higher copays or coverage denials.

After Submission: Tracking Your Request

Confirmation Steps

  • Record confirmation number from submission
  • Document submission date for timeline tracking
  • Set calendar reminders for follow-up calls

Status Check Schedule

  • Day 3: Confirm receipt and completeness
  • Day 10: Check for any additional information requests
  • Day 20: Follow up if no decision received
  • Day 30: Standard decision deadline (expedite if urgent)

What to Record

  • All reference numbers and case IDs
  • Names and contact information of representatives spoken with
  • Dates and outcomes of all communications
  • Any additional documentation requested

Common Denial Reasons & How to Avoid Them

Denial Reason Prevention Strategy Appeal Evidence
Missing Factor IX confirmation Submit recent lab results with clear values Certified lab report showing <40% activity
Inhibitor status not addressed Include Bethesda assay results Negative inhibitor screen or management plan
Step therapy not met Document prior trials and failures Treatment records showing inadequate response
Dosing exceeds limits Justify with clinical guidelines FDA labeling and specialist recommendations
Site of care restrictions Confirm home infusion approval Medical necessity for home administration

Five Critical Pitfalls to Avoid

  1. Incomplete lab work - Always include both Factor IX level and inhibitor status
  2. Missing prior treatment history - Document all previous factor products tried
  3. Vague medical necessity - Be specific about why Idelvion is required over alternatives
  4. Wrong specialty pharmacy - Use CenterWell to avoid network issues
  5. Missing deadlines - Track all submission and appeal timelines carefully

For complex cases where documentation requirements seem overwhelming, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific rules.

Appeals Process in Georgia

Internal Appeal (First Level)

  • Timeline: 65 days from denial date to file
  • Decision time: 30 days standard, 72 hours expedited
  • Submit to: Humana member services or provider portal
  • Required: New evidence supporting medical necessity

External Review (Second Level)

If Humana denies your internal appeal, Georgia law provides state-administered external review:

  • Deadline: 60 days from final internal denial
  • Cost: Free for consumers
  • Submit to: Georgia Department of Insurance Consumer Services
  • Phone: 1-800-656-2298
  • Timeline: 30 business days standard, 72 hours expedited
  • Binding: If approved, Humana must cover the medication

Required Documentation for Appeals

  • Final denial letter from Humana
  • Completed external review application (available on Georgia DOI website)
  • All supporting medical records
  • Prescriber's updated statement of medical necessity
  • Evidence of prior authorization attempts

Quick Reference Checklist

Before You Start

  • Confirm active Humana coverage with specialty drug benefit
  • Gather Factor IX level results (<40% confirms hemophilia B)
  • Obtain inhibitor testing results (Bethesda assay)
  • Collect prior treatment records and outcomes
  • Verify prescriber information (NPI, DEA numbers)

Clinical Documentation

  • Confirmed hemophilia B diagnosis with ICD-10 code D67
  • Specific Factor IX activity level documented
  • Inhibitor status clearly stated
  • Medical necessity for extended half-life product explained
  • Proposed dosing regimen with clinical justification
  • Safety monitoring plan included

Submission Requirements

  • Complete member information (ID, DOB, contact)
  • Correct Idelvion strength and NDC number
  • HCPCS code J7202 for billing
  • All required attachments included
  • Submitted through Humana provider portal or verified fax

After Submission

  • Confirmation number recorded
  • Follow-up schedule established
  • CenterWell Specialty Pharmacy contacted for prescription transfer
  • Appeal deadlines noted (65 days internal, 60 days external)

From our advocates: We've seen cases where patients initially received denials for Idelvion due to incomplete inhibitor testing documentation. After working with their hematologist to submit comprehensive Bethesda assay results and a detailed letter explaining the clinical rationale for extended half-life therapy, the appeal was successful within two weeks. The key was demonstrating that standard half-life products required more frequent dosing that impacted treatment adherence and quality of life.

Frequently Asked Questions

How long does Humana prior authorization take for Idelvion in Georgia? Standard decisions are made within 30 days. Expedited reviews for urgent cases take up to 72 hours with proper clinical documentation of urgency.

What if Idelvion is not on Humana's formulary? You can request a formulary exception with strong medical necessity documentation. Focus on clinical superiority over formulary alternatives and patient-specific factors.

Can I request an expedited appeal in Georgia? Yes, both Humana internal appeals and Georgia external reviews offer expedited timelines (72 hours) when clinical urgency is documented by your physician.

Does step therapy apply if I've used other factor products outside Georgia? Treatment history from other states counts toward step therapy requirements. Provide complete documentation of all prior factor replacement therapies and outcomes.

What happens if CenterWell Specialty Pharmacy is out of stock? Contact CenterWell immediately to arrange alternative sourcing or temporary supply. Humana may approve short-term use of another network pharmacy with prior authorization.

Important: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances and plan specifics. For personalized assistance with complex cases, Counterforce Health helps patients and clinicians navigate insurance approvals by creating targeted appeals based on each plan's specific requirements.

Disclaimer: Insurance policies change frequently. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For additional consumer assistance in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

Sources & Further Reading

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