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Humana Dual Fully Integrated Illinois prior authorization and notification list
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Defines prior authorization and notification requirements for medications and certain services for Humana Dual Fully Integrated (HMO D-SNP) Illinois plans; applies to providers furnishing covered items or services to affected Humana members.
Policy Summary
PayerHumana
PolicyHumana Dual Fully Integrated Illinois prior authorization and notification list
Policy CodePolicy N/A
Change TypeAdministrative — no material coverage changes
Effective DateJul 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization via CoverMyMeds, phone (866-461-7273 TTY 711) or fax (888-447-3430) before providing listed medications.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
90-daygrace period for active courses of treatment
3ways to initiate prior authorization
up to 6max diagnosis codes per request
866-461-7273prior auth phone
888-447-3430prior auth fax
HCPCS/CPTbilling codes provided
Coverage criteria and medication list
Coverage stance and criteria
Covered when ALL of the following are met:
Medications delivered in the provider's office, clinic, outpatient or home setting require prior authorization before being provided or administered.
Services and items meet Medicare/CMS medical necessity and coverage guidelines.
When applicable, step therapy requirements for Medicare Part B medications are followed (see Humana Part B Step Therapy PDL).
Urgent or emergent services are excluded from prior authorization requirements.
For new Humana members, active courses of treatment started prior to enrollment may continue without prior authorization for a 90-day transition period where applicable.
Failure to obtain required prior authorization may result in retrospective medical necessity review and potential financial penalties or reduced benefits.
Coverage criteria and procedural requirements (excerpt)
Requirements and procedural expectations (excerpt):
Prior authorization is required for drugs listed on the prior authorization and notification list; providers must submit requests via the specified submission methods or fax forms noted in the list.
All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims when applicable (‡ flag).
Some products are subject to step therapy through a Humana-preferred drug as part of preauthorization (flagged with **); follow the Part B Step Therapy PDL and coverage policies.
Certain preauthorization requests for transplant-related therapies will be reviewed by the Humana National Transplant Network; follow the provided fax/phone/email submission channels (†† flag).
Prior authorization and billing criteria (excerpt)
Prior authorization and billing criteria (excerpt):
Listed medications require prior authorization or provider notification per the Humana prior authorization list; follow the Humana instructions for submitting requests.
For shared HCPCS and NOC billing codes, the corresponding NDC must be included on claims (‡).
Step therapy requirements may apply for selected medications and are indicated by the ** flag; providers must satisfy step requirements where applicable as part of authorization.
Transplant-related prior authorization requests are subject to review by the Humana National Transplant Network and must follow the specified submission methods (fax/phone/email).
Medication prior authorization entries (sample)
Selected medication entries from the prior authorization and notification list (sample):
Billing and coding references
Billing Instructionsmixed
| Billing rule | All shared HCPCS codes and not otherwise classified codes require a corresponding National Drug Code (NDC) to be billed on all claims. |
| Max diagnosis codes | Up to a maximum of 6 diagnosis codes per authorization request. |
| Step therapy | Some drugs require step therapy through a Humana-preferred drug as part of preauthorization (see drug list for **). |
| Transplant review | Preauthorization requests for transplant-related drugs will be reviewed by the Humana National Transplant Network (fax 502-508-9300; phone 866-421-5663; transplant@humana.com). |
Examples of drug billing codesHCPCS
Prior authorization process and provider instructions
Prior Authorization
Exceptions - urgent/emergent services
Urgent or emergency services do not require prior authorization or referrals. If a member presents with an urgent or emergent condition, providers should deliver necessary care immediately and may notify Humana after the service is rendered. Retrospective review may be performed to confirm medical necessity, but lack of prior authorization for urgent/emergent care will not be used as a basis to deny coverage when the service met emergency care criteria.
- Do not delay clinically necessary emergency treatment to obtain prior authorization.
- Providers may notify Humana after the emergent/urgent service; follow plan-specific notification processes when feasible.
- Services provided for urgent or emergent conditions are subject to retrospective medical necessity review but are not denied solely for lack of prior authorization.
Notation legend and definitions
Prior authorization (definition)
DefinitionPrior authorization is the process through which the healthcare provider must obtain advance approval from the plan to determine whether an item or service will be covered.
ScopeApplies to medications delivered in the provider's office, clinic, outpatient or home settings and to services that must meet Medicare/CMS medical necessity guidelines.
ExceptionInvestigational and experimental procedures and devices usually are not covered; consult Evidence of Coverage or Humana for confirmation.
Document notation legend
* (asterisk)New preauthorization requirement
† (dagger)New-to-market drug addition
‡ (double dagger)All shared HCPCS and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims
HCPCS shared/NOC NDC billing requirement
Requirement summaryAll shared HCPCS codes and not otherwise classified (NOC) codes must include a corresponding National Drug Code (NDC) on claims
Affected codesShared HCPCS and NOC codes (e.g., C9399, J3490) are noted in the drug list as requiring NDCs
Submission impactClaims for affected products without the corresponding NDC may not meet billing requirements—follow listed notation when submitting authorization and claims
Step therapy flag
Flag meaning** indicates step therapy is required through a Humana-preferred drug as part of preauthorization
Where usedStep therapy flag appears next to specific Part B medications in the prior authorization list
Action for providersConsult Humana's Part B Step Therapy Preferred Drug List and coverage criteria when submitting authorization
Notation legend
* (new preauthorization)Indicates a new preauthorization requirement has been added for the listed product
† (new-to-market)Denotes a new-to-market drug addition to the list
†† (transplant review)Indicates requests will be reviewed by the Humana National Transplant Network (submission contact details provided)
Step therapy required through a Humana-preferred drug
Step therapy requirementStep therapy may be required through a Humana-preferred drug as part of preauthorization (flagged with **)
Relation to preauthorizationStep therapy is enforced during the preauthorization decision process for flagged products
Reference materialsSee Humana's Medicare Part B Step Therapy Preferred Drug List and coverage policies for details
NDC requirement for shared HCPCS and NOC codes
Billing ruleAll shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims
ExamplesC9399 and J3490 are listed in the document as examples of codes that require an NDC when billed
Referenced in list entriesEntries in the prior authorization list include the ‡ notation to signal this billing requirement
Humana National Transplant Network review
Review bodyPreauthorization requests for transplant-related items will be reviewed by the Humana National Transplant Network
Submission faxFax transplant requests to 502-508-9300
Submission phone/emailPhone 866-421-5663 (Mon–Fri 7 a.m.–7 p.m. Central); email transplant@humana.com
New preauthorization requirement
New preauthorization marking* denotes a new preauthorization requirement for the listed product
Where it appearsMarked next to individual drug entries throughout the prior authorization list
Provider actionFollow instructions on the list and submit the required fax forms or electronic requests for newly added preauthorization requirements
New-to-market drug addition
New-to-market marking† denotes a new-to-market drug addition to the prior authorization list
ImplicationNew-to-market drugs are added to the list and may carry special submission or review notes
Provider guidanceCheck the drug entry for additional flags (e.g., ‡, **) and follow submission instructions
‡ (HCPCS/NOC NDC billing requirement)
Symbol meaning‡ indicates shared HCPCS and NOC codes require a corresponding NDC on all claims
Where usedAppears beside products such as Prevymis (C9399, J3490) and other entries requiring NDC billing
Billing implicationWhen ‡ is present, include the NDC on all claims and in authorization/notification submissions as applicable
** (step therapy requirement)
Symbol meaning** indicates step therapy is required through a Humana-preferred drug as part of preauthorization
Examples in listMultiple injectable and specialty products in the list are flagged with ** to denote step therapy
Provider actionDocument prior trials of preferred drugs when submitting authorization for **-flagged products
†† (transplant review)
Symbol meaning†† indicates preauthorization requests will be reviewed by the Humana National Transplant Network
Submission channelsFax 502-508-9300; phone 866-421-5663; email transplant@humana.com
HoursMonday–Friday, 7 a.m.–7 p.m. Central for transplant review phone support
Policy Summary
PayerHumana
PolicyHumana Dual Fully Integrated Illinois prior authorization and notification list
Policy CodePolicy N/A
Change TypeAdministrative — no material coverage changes
Effective DateJul 1, 2026
Next Review DateN/A
Key ActionObtain prior authorization via CoverMyMeds, phone (866-461-7273 TTY 711) or fax (888-447-3430) before providing listed medications.
SourceLink
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