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Prior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia

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Governs prior authorization and notification requirements for medications and related services delivered in office, clinic, outpatient or home settings for Humana Dual Fully Integrated (HMO D-SNP) Virginia plans; affects participating providers and delegated networks submitting requests for covered items and services. Applies alongside Medicare coverage guidelines.

Policy Summary

PayerHumana

PolicyPrior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization before providing any listed medication and initiate requests via CoverMyMeds, phone 866-461-7273 (TTY: 711) or fax 888-447-3430.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Initiation methods

866-461-7273Phone

888-447-3430Fax

VirginiaApplies to

6Max diagnosis codes

90 daysActive treatment window

Coverage criteria and list overview

Coverage stance for listed medications

Medications listed below require prior authorization or notification. Providers must obtain authorization before administration and follow Medicare coverage guidelines and Humana medical necessity criteria.

ALL of the following

Prior authorization or notification is required for the listed medication before it is provided or administered.
All services must meet Medicare coverage guidelines and be medically necessary per CMS and Humana policies.
Providers must use the Humana prior authorization request process and the fax forms available on Humana's provider prior authorization notification lists website.

Coverage and administrative requirements for listed medications

Administrative notes and billing requirements that apply to medications on the prior authorization/notification list.

Policy Summary

PayerHumana

PolicyPrior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization before providing any listed medication and initiate requests via CoverMyMeds, phone 866-461-7273 (TTY: 711) or fax 888-447-3430.

SourceLink

On This Page

Medications requiring prior authorization/notification (T–Z and blood-clotting factors excerpt)

Partial excerpt — selected medications from the T–Z range and blood-clotting factors that require prior authorization/notification, including billing codes and special markers.

ANY of the following

Somatuline Depot — generic: lanreotide — Billing code: J1930 — marked ‡ (NDC required).
Spevigo IV — generic: spesolimab-sbzo — Billing code: J1747.
Spinraza — generic: nusinersen — Billing code: J2326.
Stelara IV — generic: ustekinumab — Billing code: J3358 — marked ‡ for NDC requirement.
Sustol — generic: granisetron — Billing code: J1627.
Syfovre — generic: pegcetacoplan — Billing code: J2781.
Zynlonta — generic: loncastuximab tesirine-lpyl — Billing code: J9359.
Zynteglo †† — generic: betibeglogene autotemcel — Billing code: J3393 — transplant network review required (††).
Zynyz — generic: retifanlimab-dlwr — Billing code: J9345.
Advate ‡ — antihemophilic factor, human recombinant — Billing code: J7192 — Blood-clotting Factors category.
Adynovate — antihemophilic factor [recombinant], PEGylated — Billing code: J7207 — Blood-clotting Factors.
Afstyla — antihemophilic factor (recombinant) single chain — Billing code: J7210 — Blood-clotting Factors.
Hemlibra ** — emicizumab-kxwh — Billing code: J7170 — Blood-clotting Factors — step therapy marker **.
Hemgenix — etranacogene dezaparvovec-drlb — Billing code: J1411 — Blood-clotting Factors.
Roctavian — valoctocogene roxaparvovec-rvox — Billing code: J1412 — Blood-clotting Factors.

Prior authorization / notification list (partial) — entries and administrative markers

Selected prior authorization list entries and their operational notes (partial). Preserve markers and actions required by providers.

ALL of the following

Each list entry provides: Brand name, Generic name, Billing codes (where applicable), and markers (*, †, ‡, **, ††) with their meanings.
Examples from the list: Blenrep (belantamab mafodotin-blmf) — Billing codes: C9399, J3490, J3590, J9999 — shared/NOT-CODES require NDC on claims (‡).
Briumvi (ublituximab-xiiy) — Billing code: J2329 — step therapy or other markers may apply as indicated on the entry.
Herceptin (trastuzumab) and related formulations (Herceptin Hylecta, Hercessi IV, Ogivri, Ontruzant, Ocrevus Zunovo, etc.) include specific HCPCS/J-codes listed per product and may be marked with ** or ‡ as shown.
Omisirge (omidubicel-onlv) — Billing codes: C9399, J3490, J3590 — marked †† and ‡ where applicable; transplant network review required for †† entries.
Providers must consult the Humana prior authorization website for the correct fax forms and submission instructions associated with each listed medication.

Billing and code guidance

Examples of medication billing codes listedHCPCS

Q2055	Abecma billing code
J9264	Abraxane billing code
J3262	Actemra IV billing code
J0791	Adakveo billing code

Examples of medication billing codes in excerptmixed

J9382	billing code listed for eculizumab-aeeb (Bkemv IV)
Q5152	billing code listed for belantamab mafodotin-blmf (Blenrep)
J9039	billing code listed for blinatumomab (Blincyto)
J9046	billing code listed for bortezomib (Dr. Reddy's)
J0567	billing code listed for cerliponase alfa (Brineura)
J2329	billing code listed for ublituximab-xiiy (Briumvi)
J0585	billing code listed for onabotulinumtoxinA (Botox)

Sample HCPCS/J-codes in listHCPCS

J9393	fulvestrant (Teva)
J9331	sirolimus protein-bound particles for injectable suspension (Fyarro)

Ocrevus codesHCPCS

J2350	ocrelizumab (Ocrevus)
J2351	ocrelizumab and hyaluronidase-oscq (Ocrevus Zunvo)

Examples of billing/HCPCS codes presentHCPCS

J2802	listed billing code for Nucala (mepolizumab)
J2182	alternative billing code listed for Nucala (mepolizumab)
J2350	billing code for Ocrevus (ocrelizumab)
C9399	not otherwise classified HCPCS code used for several drugs (requires corresponding NDC)
J3490	not otherwise classified code used for several drugs (requires corresponding NDC)
J3590	not otherwise classified code used for several drugs (requires corresponding NDC)

Representative HCPCS/J-codes listedHCPCS

J1930	Somatuline Depot (lanreotide) - example HCPCS/J-code
J2356	Tezspire (tezepelumab-ekko) billing code
J1303	Ultomiris (ravulizumab-cwvz) billing code
J7192	Advate (antihemophilic factor) billing code

Sample HCPCS/J codes from listHCPCS

J9282	mitomycin (as listed)
J9359	loncastuximab tesirine-lpyl
J3393	betibeglogene autotemcel
J9345	retifanlimab-dlwr
J7192	antihemophilic factor (various products referenced)
J7207	antihemophilic factor [recombinant], PEGylated (Adynovate)
J7210	antihemophilic factor (recombinant) single chain (Afstyla)
J7173	concizumab-mtci (Alhemo)
J1411	etranacogene dezaparvovec-drlb (Hemgenix)
J1412	valoctocogene roxaparvovec-rvox (Roctavian)

inv-14: NDC requirement for shared HCPCS/not otherwise classified codes

RequirementAll shared HCPCS and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims.

ApplicabilityApplies to entries flagged with the ‡ symbol throughout the Humana D-SNP Virginia prior authorization list.

ExamplesCommon NOC/shared codes referenced include C9399, J3490, J3590 (see drug entries).

PurposeEnsures specific drug identification on claims when multiple products share HCPCS/NOC codes.

How to request prior authorization and provider responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required before providing the medications listed on this document when delivered in the provider's office, clinic, outpatient or home setting. Providers must obtain advance approval from Humana where indicated; failure to obtain prior authorization may result in financial penalties, reduced benefits for the member, and retrospective medical necessity review.

Prior authorization initiation methods: Online via CoverMyMeds (http://www.covermymeds.com/); Phone: 866-461-7273 (TTY: 711), Monday - Friday, 8 a.m. - 11 p.m. Eastern time; Fax: 888-447-3430. Request forms are available on Humana's prior authorization for professionally administered drugs website.
Certain items flagged †† (transplant-reviewed) will be reviewed by the Humana National Transplant Network (see transplant contact details).
All services must meet Medicare/CMS medical necessity guidelines and member Evidence of Coverage; investigational or experimental procedures are generally not covered.

Documentation Required

Information required for prior authorization requests

When submitting a prior authorization request or notification, include complete patient and service details to expedite review.

Patient name, date of birth, and Humana member ID number
Date of actual service or hospital admission
HCPCS code(s) and diagnosis codes (primary and secondary) — up to 6 diagnosis codes per request
Service location (inpatient: acute hospital, skilled nursing, hospice; outpatient: telehealth, office, home, off‑campus outpatient hospital, on‑campus outpatient hospital, ambulatory surgery center)
Tax Identification Number (TIN) and National Provider Identifier (NPI) for facility and rendering provider
Caller/requester name and phone number and attending provider's phone number
Relevant clinical information and documentation to support medical necessity

Billing Rule

Medication-specific prior authorization instructions

Medication-specific prior authorization instructions accompany each drug entry in the list. For each medication entry providers should: use the listed billing/HCPCS codes when submitting requests and access Humana's fax request forms to submit clinical information.

Each medication entry shows: Brand name, generic name where applicable, billing codes (HCPCS/CPT/Q-codes) and any special markers (e.g., * = new preauthorization, † = new‑to‑market, ** = step therapy required, ‡ = NDC required on claim, †† = transplant-reviewed).
Use the billing codes shown in the list when requesting prior authorization and when billing claims.
If step therapy (**) is indicated, follow the Humana-preferred drug pathway as part of the preauthorization.
For HCPCS or miscellaneous codes (‡), ensure the corresponding National Drug Code (NDC) is billed on all claims.

Prior Authorization

Transplant preauthorization submission guidance

Preauthorization requests for items marked †† are reviewed by the Humana National Transplant Network. Providers should submit transplant-related preauthorization requests directly to the Transplant Network using one of the following methods to ensure timely review.

Fax: 502-508-9300
Phone: 866-421-5663, Monday – Friday, 7 a.m. – 7 p.m., Central time
Email: transplant@humana.com

Note

How to request prior authorization

General submission options and instructions: use the online, phone or fax options listed below; access Humana’s prior authorization fax forms to ensure all required fields are included. Submitting complete clinical documentation at the time of request helps avoid delays.

Online: CoverMyMeds (http://www.covermymeds.com/)
Phone: 866-461-7273 (TTY: 711), Monday - Friday, 8 a.m. - 11 p.m., Eastern time
Fax: 888-447-3430 (request forms available on Humana's prior authorization for professionally administered drugs website)
For transplant-reviewed items (††) use Humana National Transplant Network contact options (fax/phone/email) listed above.

Notational keys and definitions used in the list

inv-29: prior authorization — definition of prior authorization process

DefinitionPrior authorization is a process through which the healthcare provider must obtain advance approval from the plan that an item or service will be covered.

ScopeApplies to medications delivered in provider office, clinic, outpatient or home settings listed on the D-SNP Virginia prior authorization list.

RequirementProviders must obtain prior authorization before providing or administering listed medications unless otherwise noted.

inv-30: document symbols and notes — meanings of †, ‡, ** and other symbols

† (dagger)Indicates a new-to-market drug addition to the list.

‡ (double dagger)Indicates shared HCPCS and not otherwise classified codes require a corresponding NDC to be billed on all claims.

** (double asterisk)Indicates step therapy is required through a Humana-preferred drug as part of preauthorization.

†† (double dagger pair)Indicates preauthorization requests will be reviewed by the Humana National Transplant Network (submission options: fax 502-508-9300, phone 866-421-5663 Mon–Fri 7 a.m.–7 p.m. CT, or email transplant@humana.com).

inv-31: List notation (brand/generic/code structure)

List structureEntries use a two-position notation: 1 = Brand medication name; 2 = Generic medication name or billing codes.

ExampleExample format shown: 'fulvestrant (Teva), 1 = fulvestrant; 2 = J9393' — where '1' shows brand/generic pairing and '2' shows billing code.

UsageUsed consistently across the Humana D-SNP Virginia prior authorization and notification list to present product and code information.

inv-32: NDC requirement for shared HCPCS (‡)

RequirementEntries marked with the ‡ symbol (shared HCPCS/NOC) require a corresponding NDC on claims for all shared HCPCS and not otherwise classified codes.

Where notedSeen on immune globulin and other products (e.g., GamaSTAN ‡, Gammagard ‡, Panzyga * **, Xyntha ‡ etc.).

Submission impactProviders should include the applicable NDC when billing to ensure correct product identification and claims processing.

inv-33: Step therapy (**) — step therapy required through a Humana-preferred drug as part of preauthorization

Definition** indicates step therapy is required; the patient must try a Humana-preferred drug first as part of the preauthorization process.

ReferenceSee Humana's Medicare Part B Step Therapy Preferred Drug List for details on preferred agents and required trials.

ApplicabilityApplied to medication entries flagged with ** across the prior authorization list.

inv-34: Step therapy — step therapy notation duplicate (definition)

DefinitionStep therapy (**) requires trial of a Humana-preferred drug prior to coverage of the requested agent as part of preauthorization.

Where usedFlagged on multiple drug entries (e.g., Fylnetra **, Herceptin (IV) **, Gel-One **).

ImplicationPrior authorization approvals may be contingent on documentation of prior trial(s) with preferred agents.

inv-35: Humana National Transplant Network review — †† definition with contact info reference

†† meaningIndicates preauthorization requests are reviewed by the Humana National Transplant Network.

Contact methodsSubmission options: fax 502-508-9300; phone 866-421-5663 (Mon–Fri 7 a.m.–7 p.m. CT); email transplant@humana.com.

ApplicabilityUsed for transplant-related products listed with the †† marker (e.g., Tecartus ††, Tecelra ††, Zynteglo ††).

inv-36: ‡ (HCPCS/NDC requirement) — symbol definition

Symbol‡ indicates that HCPCS and not otherwise classified codes require a corresponding NDC to be billed on all claims.

ExamplesAppears on products such as GamaSTAN ‡, Gammagard ‡, Pegvaliase-pqpz ‡ (Palynziq), and blood-clotting factors like Advate ‡.

Billing noteFailure to include the NDC for shared/NOC codes may affect claim adjudication and accurate product identification.

inv-37: ** (step therapy) — symbol definition

Symbol** denotes step therapy is required; a Humana-preferred drug trial is part of preauthorization requirements.

Clinical documentationAuthorization requests should include evidence of prior trials or rationale why step therapy is not appropriate.

ExamplesUsed on multiple entries (e.g., Fylnetra **, Gel-One **, Tecentriq **).

inv-38: †† (transplant review) — symbol definition and submission note

Symbol†† identifies items whose preauthorization requests are reviewed by the Humana National Transplant Network.

Submission noteTransplant reviews can be submitted by fax (502-508-9300), phone (866-421-5663 Mon–Fri 7 a.m.–7 p.m. CT), or email (transplant@humana.com).

Example productsExamples include cell and gene therapies listed with †† (e.g., Tecartus, Tecelra, Zynteglo).

inv-40: * (new preauthorization requirement) — symbol definition

Symbol* indicates a new preauthorization requirement has been added for the listed product.

ContextDisplayed in the list header and repeated with entries that are newly subject to preauthorization (e.g., Asceniv * **, Gammaplex * **).

Action for providersVerify newly added prior authorization requirements before providing the product to avoid potential financial or coverage issues.

inv-41: NDC requirement for shared HCPCS/NOC codes — duplicate definition for later chunks

Requirement restatedAll shared HCPCS and not otherwise classified (NOC) codes require a corresponding NDC on claims; this note is repeated in multiple sections of the list.

Where repeatedPresent in headers and footers of list sections (see chunks 36, 57, 73, 93, 96, 97).

Provider actionInclude the NDC when billing products that share HCPCS or use NOC codes to ensure proper adjudication.

inv-42: step therapy note — duplicate step therapy definition for later chunks

Step therapy definitionStep therapy (**) requires trial of a Humana-preferred drug and is enforced as part of the preauthorization process for entries marked **.

DocumentationAuthorization requests should document prior medication trials or clinical justification for bypassing step therapy.

List presenceRepeated across multiple list sections to indicate where step therapy applies (see examples in chunks 36, 37, 57).

inv-43: new drug / new preauthorization markers — † and * definitions repeated for later sections

† (dagger) meaningMarks new-to-market drug additions to the prior authorization list.

* (asterisk) meaningMarks items that now have a new preauthorization requirement.

UsageBoth markers are shown in headers and with specific drug entries to draw attention to changes in authorization status.