How to request prior authorization — initiation pathways

Except where noted, prior authorization for medications may be initiated in one of three ways: Online via CoverMyMeds (http://www.covermymeds.com/), by phone at 866-461-7273 (TTY: 711), Monday – Friday, 8 a.m. – 11 p.m. Eastern time, or by fax to 888-447-3430. For transplant-related preauthorization requests, submit via fax to 502-508-9300, by phone at 866-421-5663 (Mon–Fri, 7 a.m. – 7 p.m. Central), or by email to transplant@humana.com. Request forms are available on Humana's prior authorization for professionally administered drugs website.

• Online: CoverMyMeds (http://www.covermymeds.com/)
• Phone: 866-461-7273 (TTY: 711), Mon–Fri, 8 a.m.–11 p.m. ET
• Fax: 888-447-3430 (request forms on Humana website)
• Transplant submissions: fax 502-508-9300; phone 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT); email transplant@humana.com

Information required for prior authorization

Submit the following information with a prior authorization request or notification. Including all relevant clinical documentation up front helps expedite determinations; Humana may request additional information if needed.

• Patient name, date of birth, Humana member ID
• Date of service or hospital admission
• HCPCS code(s) and diagnosis codes (primary and secondary) — up to 6 diagnosis codes per request
• Service location (e.g., telehealth, office, home, off-campus or on-campus outpatient hospital, ambulatory surgery center)
• Tax Identification Number (TIN) and National Provider Identifier (NPI) for the facility where service is rendered and for the provider performing the service
• Caller/requester name and phone number and attending provider phone number
• Relevant clinical information and supporting documentation

Request preauthorization / provide notification — submission instructions

Access the Humana fax forms to request preauthorization or provide notification for the medications listed on the prior authorization/notification list. Billing (HCPCS/J/C) codes are provided alongside each drug entry in the list. Some entries include special markers: * = new preauthorization requirement; † = new-to-market drug; ‡ = HCPCS shared/NOC code — requires corresponding NDC on claims; ** = step therapy required; †† = transplant-reviewed item.

• Use the listed billing codes when submitting the request (HCPCS/J-codes are shown per drug)
• For ‡ codes, include the corresponding NDC on all claims
• For ** entries, follow step therapy requirements (Humana-preferred drug must be tried where applicable)
• For †† items, follow Humana National Transplant Network submission pathways

Submission notes and special processes

Submission notes and special processes: some medications are newly subject to prior authorization or are new-to-market; shared HCPCS and NOC codes require corresponding NDCs on claims; step therapy markers indicate a required trial of a Humana-preferred agent as part of preauthorization. Preauthorization denials or failure to obtain required prior authorization may result in financial penalties to the practice and reduced benefits for the patient and services may be subject to retrospective medical necessity review.

• * = New preauthorization requirement
• † = New-to-market drug addition
• ‡ = Shared HCPCS/NOC codes require corresponding NDC on claims
• ** = Step therapy required through a Humana-preferred drug as part of preauthorization
• Not obtaining prior authorization may lead to financial penalties and retrospective denials

Prior authorization notes and contact

Contact and legend notes: request forms are available on Humana's prior authorization for professionally administered drugs website. For questions about the list or submission process, use the phone and fax numbers above. For transplant-related questions or to submit transplant reviews, contact the Humana National Transplant Network (fax 502-508-9300; phone 866-421-5663; email transplant@humana.com).

• Request forms available on Humana prior authorization for professionally administered drugs site
• General prior authorization phone: 866-461-7273 (TTY: 711)
• General prior authorization fax: 888-447-3430
• Transplant review: fax 502-508-9300; phone 866-421-5663; email transplant@humana.com

How to request prior authorization — blood-clotting factors

Blood-clotting factors require prior authorization. Use the Humana fax forms to submit requests or notifications and include the required clinical documentation and billing codes shown below. Shared/NOC HCPCS codes (‡) require the corresponding NDC on claims.

• Advate — J7192 (antihemophilic factor, human recombinant) ‡
• Adynovate — J7207 (antihemophilic factor [recombinant], PEGylated)
• Afstyla — J7210 (antihemophilic factor [recombinant] single chain)
• Alhemo ** — J7173 (concizumab-mtci)
• Alphanate — J7186 (antihemophilic factor/von Willebrand factor complex [human])
• AlphaNine SD — J7193 (coagulation factor IX [human])
• Alprolix — J7201 (coagulation factor IX [recombinant])
• Altuviiio — J7214 (efanesoctocog alfa)
• Benefix ‡ — J7195 (coagulation factor IX [recombinant])
• Beqvez — J1414 (fidanacogene elaparvovec-dzkt)
• Coagadex — (see list)
• Nuwiq — J7209 (simoctocog alfa)
• Obizur — J7188 (antihemophilic factor [recombinant], porcine sequence)
• Profilnine — J7194 (factor IX complex)
• Qfitlia ** ‡ — J7174 (fitusiran)
• Rebinyn — J7203 (Coagulation Factor IX [Recombinant], GlycoPEGylated)
• Recombinate ‡ — J7192 (antihemophilic factor [recombinant])
• Rixubis — J7200 (coagulation factor IX [recombinant])
• Roctavian — J1412 (valoctocogene roxaparvovec-rvox)
• SevenFact — J7212 (coagulation factor VIIa [recombinant]-jncw; eptacog beta)
• Tretten — J7181 (coagulation factor XIII A-subunit [recombinant])
• Vonvendi — J7179 (von Willebrand factor [recombinant])
• Wilate — J7183 (von Willebrand factor / coagulation factor VIII complex [human])
• Xyntha ‡ / Xyntha Solofuse ‡ — J7185 (antihemophilic factor [recombinant])

Prior authorization required — blood-clotting factors

Prior authorization is required for the blood-clotting factor products listed. Some products are marked for step therapy (**) or shared HCPCS/NOC (‡) — ensure step therapy requirements are met and include the corresponding NDC on claims for ‡ entries. Failure to include the NDC for shared/NOC HCPCS codes or to obtain required prior authorization may result in claim denials or retrospective review.

• Prior authorization required for all listed blood-clotting factors
• ** indicates step therapy required — document trials of Humana-preferred agents when applicable
• ‡ indicates HCPCS shared/NOC — include corresponding NDC on claim submissions
• Provide complete clinical documentation to avoid retrospective medical necessity review or financial penalties

Step therapy and billing requirements

Step therapy and billing requirements: entries marked ** require completion of step therapy through a Humana-preferred drug as part of the preauthorization process. Entries marked ‡ are shared or NOC HCPCS codes and require a corresponding NDC to be billed on all claims. Newly added prior authorization requirements (*) and new-to-market markers (†) appear throughout the list; follow the submission instructions and include requested documentation to support medical necessity.

• ** = Step therapy required (document prior trials and responses)
• ‡ = Shared HCPCS/NOC — include corresponding NDC on claims
• * = New preauthorization requirement
• † = New-to-market drug addition
• For step therapy, include documentation of previous agent(s) tried, dates, dosages, and clinical response