Humana Dual Fully Integrated Illinois prior authorization and notification list
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Governs prior authorization and notification requirements for medications and certain services for Humana Dual Fully Integrated (HMO D-SNP) Illinois members; affects participating providers, facilities, and delegated networks who must obtain prior authorization or provide notifications as specified.
No material clinical or coverage changes in this revision.
Prior Authorization and Notification Coverage Criteria
inv-01: Prior authorization and exceptions
Medications and certain services listed require prior authorization; step therapy and coverage determinations follow Humana and CMS guidance.
inv-02: Prior authorization / notification medication entries (examples)
Medications listed require prior authorization or notification as indicated; see symbol legend for special conditions (e.g., ‡ NDC billing requirement, ** step therapy, †† transplant review).
inv-03: Prior authorization and billing criteria overview
This section enumerates drugs that require prior authorization or notification and includes billing codes and special notes (step therapy, NDC billing requirement, transplant routing).
inv-04: Prior authorization medication entries (partial)
Medications listed require prior authorization or notification; special annotations (e.g., *, †, ‡, **, ††) apply as noted in the legend and list entries.
inv-05: Prior authorization/notification drug list
Listed products require prior authorization or notification as indicated; follow submission instructions and billing rules in the notes for each entry.
Billing and Coding (HCPCS / J-codes / NDC)
| J2278 | ziconotide (Prialt) |
Provider Responsibilities and Submission Instructions
Consequences of noncompliance
Prior authorization must be obtained in advance when required by this list. Failure to obtain required prior authorization may result in financial penalties to the practice, reduced benefits for the patient per the provider contract and the member's Evidence of Coverage, and claims subject to retrospective medical necessity review.
- Services or medications provided without prior authorization may be denied or partially paid.
- Providers should verify benefits and prior authorization requirements with Humana before providing services.
Documentation requirements
Submit all relevant clinical and administrative documentation with the prior authorization request to expedite review. Incomplete requests may delay determination and will be returned for additional information.
- Include patient name, date of birth and Humana member ID.
- Provide date of service or hospital admission and service location (outpatient, office, home, ASC, etc.).
- List HCPCS codes and up to 6 diagnosis codes (primary and secondary).
- Include facility TIN/NPI, rendering provider TIN/NPI, caller/requester name and phone number, and attending provider phone number.
- Attach relevant clinical information (progress notes, labs, imaging, prior therapies).
Step therapy for Medicare Part B medications
Humana maintains a Medicare Part B Step Therapy Preferred Drug List (PDL). Review the Part B Step Therapy PDL and Humana coverage policies to confirm preferred drugs and cross-benefit strategies before submitting a request.
- Affected Medicare Part B medications are noted with a step therapy indicator on the Medicare PAL.
- Step therapy may require trials across benefits (Part B and Part D); check the Part B Step Therapy PDL for details.
- Designation as preferred does not guarantee exemption from step therapy — follow specific coverage criteria.
How to request prior authorization (example entry)
Example prior authorization entry fields — include these to help ensure a complete submission and faster processing.
- Patient name, DOB, Humana member ID.
- Date of actual service or hospital admission.
- HCPCS code(s) and diagnosis code(s) (up to 6).
- Service location and attending provider contact information.
- Relevant clinical documentation supporting medical necessity.
Prior authorization and transplant review note
Some preauthorization requests (for transplant-related services) will be reviewed by the Humana National Transplant Network. Transplant preauthorization requests may be submitted by fax, phone, or email to the contacts below.
- Transplant fax: 502-508-9300
- Transplant phone: 866-421-5663, Monday–Friday, 7 a.m.–7 p.m. Central time
- Transplant email: transplant@humana.com
Legend / provider requirements
Legend and provider requirements — symbols and special notes used throughout this list. Review these before submitting requests.
- * New preauthorization requirement
- † New-to-market drug addition
- ‡ All shared HCPCS and NOC codes require a corresponding NDC to be billed on all claims
- ** Step therapy required through a Humana-preferred drug as part of preauthorization
- †† Preauthorization requests reviewed by Humana National Transplant Network
Billing requirement for shared HCPCS/NOC codes
When billing codes that are shared HCPCS or not otherwise classified (NOC) are used, a corresponding National Drug Code (NDC) must be submitted on all claims to identify the specific product administered.
- This requirement applies to all shared HCPCS/NOC codes noted with the ‡ symbol on the list.
- Failure to include the corresponding NDC on the claim may result in claim processing issues or denial.
How to request prior authorization (fax forms)
Fax forms and submission channels: prior authorization for medications may be initiated via CoverMyMeds, phone, or fax. Access the fax request forms on Humana's prior authorization for professionally administered drugs website.
- 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 webpage
- Many medication entries include links to fax forms for that specific drug on the notification list.
Symbols and Key Definitions
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