By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Work With Your Doctor to Get Eylea and Lucentis Covered by Humana in North Carolina: Complete Prior Authorization Guide

Answer Box: Getting Eylea/Lucentis Covered by Humana in North Carolina

Humana requires prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab) with step therapy protocols prioritizing alternatives like Vabysmo or bevacizumab first. To get coverage in North Carolina:

  1. Gather evidence: OCT imaging, visual acuity records, and documentation of failed prior treatments
  2. Submit PA request through your ophthalmologist with clinical justification for bypassing step therapy
  3. If denied, file internal appeal within 65 days, then external review through Smart NC if needed

Timeline: Standard PA decisions take up to 14 days; expedited reviews within 72 hours for urgent cases. North Carolina's external review provides binding decisions within 45 days (72 hours if expedited).

Table of Contents

  1. Set Your Goal: Understanding Humana's Requirements
  2. Visit Preparation: Building Your Case
  3. Evidence Kit: What Your Doctor Needs
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Review Support
  6. After-Visit Documentation
  7. Appeals Process in North Carolina
  8. When to Escalate and Get Help

Set Your Goal: Understanding Humana's Requirements

Your partnership with your ophthalmologist is crucial for securing Humana coverage for Eylea or Lucentis. Humana requires prior authorization for both medications and typically mandates step therapy, meaning you'll need to try preferred alternatives first unless there's clinical justification to bypass this requirement.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for both Eylea and Lucentis Humana Provider Portal
Step Therapy Must try Vabysmo, Eylea HD, or bevacizumab first Humana formulary guidelines
Clinical Documentation OCT imaging, visual acuity, treatment history Your medical records
Appeal Deadline 65 days from denial notice Medicare.gov Appeals
External Review Through Smart NC within 120 days NC Department of Insurance
Note: If you're continuing treatment started within the last 365 days, step therapy requirements may not apply, though prior authorization is still needed.

Visit Preparation: Building Your Case

Before your appointment, organize your medical history to help your doctor build the strongest possible case for coverage.

Symptom and Treatment Timeline

Document these details to share with your ophthalmologist:

  • When vision problems started and how they've progressed
  • Previous eye treatments you've tried, including:
    • Other anti-VEGF injections (bevacizumab, ranibizumab, aflibercept)
    • Laser treatments or surgery
    • Any medications that caused side effects or didn't work
  • Current symptoms and how they affect daily activities
  • Family history of eye conditions

Functional Impact Notes

Be specific about how your vision affects your life:

  • Difficulty reading, driving, or working
  • Problems with stairs or mobility
  • Impact on independence and quality of life

This information helps your doctor demonstrate medical necessity in the prior authorization request.

Evidence Kit: What Your Doctor Needs

Your ophthalmologist will need comprehensive clinical documentation to support the prior authorization request. Here's what should be included:

Required Clinical Documentation

  1. Diagnostic Imaging
    • Recent OCT (Optical Coherence Tomography) scans showing disease activity
    • Fluorescein angiography if available
    • Visual acuity measurements using ETDRS/LogMAR when possible
  2. Treatment History
    • Documentation of previous anti-VEGF treatments and outcomes
    • Evidence of treatment failure, intolerance, or contraindications to preferred agents
    • Specific reasons why bevacizumab or other preferred options aren't suitable
  3. Clinical Justification
    • ICD-10 diagnosis codes (e.g., H35.32 for wet AMD)
    • Medical necessity rationale for bypassing step therapy
    • Treatment goals and expected outcomes
Tip: Ask your doctor's office for copies of your recent test results and treatment notes. Having these ready can speed up the PA process.

Medical Necessity Letter Structure

A well-structured letter of medical necessity is critical for approval. Counterforce Health specializes in helping patients and providers create targeted, evidence-backed appeals that turn insurance denials into approvals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each plan's requirements.

Key Components Your Doctor Should Include

  1. Patient Information
    • Full name, date of birth, Humana ID number
    • Clear diagnosis with ICD-10 codes
  2. Clinical Rationale
    • Current disease status with imaging findings
    • Prior treatment history and specific outcomes
    • Why preferred alternatives are inappropriate or ineffective
  3. Medical Necessity Statement
    • Risk of vision loss without treatment
    • Benefits of the requested medication
    • References to FDA labeling and clinical guidelines
  4. Supporting Documentation
    • Recent clinical notes
    • Imaging reports (OCT, fluorescein angiography)
    • Visual acuity records
    • Relevant medical literature

Sample Key Points for Your Doctor

"Patient presents with active choroidal neovascularization confirmed by OCT imaging, with documented treatment failure/intolerance to bevacizumab. Without timely anti-VEGF therapy with [requested medication], patient faces risk of irreversible vision loss. The requested medication is FDA-approved for this indication and clinically appropriate based on patient's specific circumstances."

Peer-to-Peer Review Support

Important: As of August 2024, Humana Medicare Advantage requires peer-to-peer review between your doctor and a Humana medical director before any denial is issued. After a denial, peer-to-peer is no longer available—only formal written appeals.

How to Support Your Doctor

  1. Be Available for Quick Scheduling
    • Peer-to-peer calls must often be scheduled within 24 hours of notification
    • Provide your doctor's office with flexible time windows
  2. Prepare a One-Page Summary
    • Work with your doctor to create a concise case summary
    • Include key clinical facts, treatment history, and urgency
  3. Emphasize Time Sensitivity
    • If delays could worsen your condition, make this clear to your doctor
    • Request expedited review if appropriate

After-Visit Documentation

Keep detailed records of all communications and decisions related to your prior authorization request.

What to Save

  • All correspondence from Humana (letters, emails, phone call notes)
  • Prior authorization forms and submission confirmations
  • Clinical documentation provided to Humana
  • Denial letters with specific reasons listed
  • Appeal submissions and tracking numbers

Using Patient Portals

  • Message your doctor through the patient portal with questions
  • Request copies of submitted documentation
  • Ask for updates on PA status and next steps
Tip: Screenshot important messages and download all documents. Portal access can sometimes be limited, and you'll need these records if you need to appeal.

Appeals Process in North Carolina

If Humana denies coverage, North Carolina offers robust appeal rights through both internal insurance company processes and external review.

Internal Appeals with Humana

  1. Timeline: 65 days from denial notice to file appeal
  2. How to Submit:
    • Online through Humana member portal
    • Mail to address on denial letter
    • Fax to number provided in denial notice
  3. Expedited Appeals: Available if delay could seriously harm your health
    • Decision within 72 hours
    • Your doctor must provide medical justification for urgency

External Review Through Smart NC

If Humana's internal appeal is denied, you can request external review through North Carolina's Smart NC program:

  • Timeline: 120 days from final internal denial
  • Process: Independent review organization makes binding decision
  • Standard Review: Decision within 45 days
  • Expedited Review: Decision within 72 hours for urgent cases
  • Contact: Call Smart NC at 1-855-408-1212 for free guidance
Note: Smart NC staff can help you fill out forms and gather documentation, though they cannot serve as your official representative.

When to Escalate and Get Help

Respectful Persistence

  • Follow up weekly on pending prior authorizations
  • Document all interactions with Humana customer service
  • Ask for supervisor if initial representatives can't help
  • Request reference numbers for all calls and submissions

Getting Professional Help

If you're facing repeated denials or complex appeals, consider getting assistance from:

  • Smart NC: Free help with appeals and external review (1-855-408-1212)
  • Medicare Ombudsman: For Medicare Advantage issues
  • Counterforce Health: Specialized service that helps turn insurance denials into successful appeals by creating targeted, evidence-backed documentation

Filing Complaints

If you believe Humana is improperly denying coverage:

Frequently Asked Questions

How long does Humana prior authorization take for Eylea/Lucentis? Standard decisions take up to 14 days; expedited reviews are completed within 72 hours if medical urgency is documented.

What if my medication is non-formulary? You can request a formulary exception with medical justification. Your doctor will need to demonstrate why formulary alternatives are inappropriate.

Can I request an expedited appeal in North Carolina? Yes, both Humana internal appeals and Smart NC external reviews offer expedited processing for urgent medical situations.

Does step therapy apply if I've been on treatment outside North Carolina? If you're continuing therapy within 365 days, step therapy requirements may not apply, but you'll still need prior authorization.

What happens if Smart NC overturns Humana's denial? The decision is binding—Humana must provide coverage within 3 business days of the external review decision.

How much do Eylea and Lucentis cost without insurance? List prices typically range from $1,200 to $2,500 per injection, varying by product and strength.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and policy terms. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212.

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