CurrentHumanaPolicy H1036-280

Humana Fully Integrated Florida prior authorization and notification list (HMO D-SNP)

Governs prior authorization and notification requirements for medications and certain services for Humana Fully Integrated Florida (HMO D-SNP) Medicare Advantage members; affects participating providers and delegated networks in Florida.

Policy Summary

PayerHumana

PolicyHumana Fully Integrated Florida prior authorization and notification list (HMO D-SNP)

Policy CodePolicy H1036-280

Change TypeAdministrative update — no material clinical or coverage changes

Effective Date07/01/2026

Next Review DateN/A

Key ActionProviders must obtain prior authorization for many provider-administered medications using CoverMyMeds, phone 866-461-7273 (TTY 711) or fax 888-447-3430; transplant-related requests use Humana National Transplant Network contacts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

07/01/2026Effective date

H1036-280Policy ID

Phone: 866‑461‑7273Contact

Prior auth requiredPrimary action

FloridaGeography

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Coverage Criteria and Authorization Requirements

Coverage stance

Medications and services listed require prior authorization and must meet Medicare medical necessity criteria; investigational/experimental procedures generally are not covered.

Prior authorization is required for medications delivered in provider settings before being provided or administered.

Services must be provided according to Medicare coverage guidelines and be medically necessary per CMS standards.

Investigational and experimental procedures and devices usually are not covered; consult the patient’s Evidence of Coverage or Humana for confirmation.

Prior authorization annotations and instructions (partial)

Annotations and procedural notes related to prior authorization requirements shown in the list:

• '‡' indicates shared HCPCS/NOC codes require a corresponding National Drug Code (NDC) to be billed on all claims.

• '**' indicates step therapy is required through a Humana-preferred drug as part of preauthorization.

• '*' denotes a new preauthorization requirement; '•' denotes new-to-market drug additions.

• '•' indicates preauthorization requests will be reviewed by the Humana National Transplant Network; submission contact methods (fax, phone, email) are provided in the product list.

Prior authorization summary (partial)

Medications listed require prior authorization and may have special billing or step therapy requirements; transplant-related requests follow separate submission/review process.

Prior authorization is required for the listed drugs; examples and billing codes are provided in the product list.

Shared HCPCS/NOC codes require a corresponding NDC to be billed on claims (denoted by '‡').

Transplant-related preauthorization requests are reviewed by the Humana National Transplant Network; contact details for fax, phone and email are provided for submission.

Prior authorization and billing criteria (product list)

Product-level prior authorization and billing code listings with special notations for step therapy and billing requirements.

Enumerated blood-clotting factor products are listed with associated HCPCS J-codes (examples include J7175, J7180, J7205, J1411, J1412, J7209, J7212).

Products marked with '‡' indicate shared HCPCS/NOC codes that require a corresponding NDC on all claims (billing requirement).

Products marked with '**' require step therapy through a Humana-preferred drug as part of preauthorization.

Products or categories noted with '*' are new preauthorization requirements; '†' denotes new-to-market additions.

Transplant-related product requests follow separate review by the Humana National Transplant Network with submission instructions (fax/phone/email) provided in the list.

Coding Examples and Billing Codes

Sample HCPCS/CPT codes for listed medicationsHCPCS

J9264	Paclitaxel protein-bound (Abraxane) billing code example
Q2055	Idecabtagene vicleucel (Abecma) billing code example
J0172	Aducanumab (Aduhelm) billing code example

Examples of HCPCS/J-codes listedHCPCS

J9331	sirolimus protein-bound particles for injectable suspension (Fyarro)
J1560	immune globulin (example: GamaSTAN)
J7326	sodium hyaluronate (Gel-One)

Sample HCPCS codes from list (partial)HCPCS

J9306	Perjeta (pertuzumab) HCPCS example
J9316	Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf) HCPCS example
J3399	Zolgensma (onasemnogene abeparvovec-xioi) HCPCS example

Sample HCPCS J-codes for listed blood-clotting factor productsHCPCS

J7175	Coagadex
J7180	Corifact
J7205	Eloctate
J7170	Hemlibra
J1411	Hemgenix
J1412	Roctavian
J7209	Nuwiq
J7212	SevenFact

Maximum diagnosis codes per request

Maximum diagnosis codes per requestUp to a maximum of 6 diagnosis codes may be submitted per authorization request.

Source contextThis threshold applies to authorization requests submitted under the H1036-280 prior authorization list for Humana Fully Integrated Florida.

Action for providersEnsure no more than six diagnosis codes are included on the initial authorization submission to avoid rejection or processing delays.

How to Request Prior Authorization and Provider Requirements

Prior Authorization

How to request prior authorization — CoverMyMeds, phone, fax

Prior authorization may be initiated online via CoverMyMeds, 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. Urgent/emergent services do not require prior authorization. Request forms are available on Humana's prior authorization for professionally administered drugs website.

Online: CoverMyMeds (www.covermymeds.com)
Phone: 866-461-7273 (TTY: 711), Mon–Fri, 8 a.m.–11 p.m. ET
Fax: 888-447-3430 (request forms available on Humana website)

Prior Authorization

Transplant preauthorization — Humana National Transplant Network review

Certain transplant-related preauthorization requests are reviewed by the Humana National Transplant Network and must be submitted to that network for review.

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

Definitions and Notation Key

Prior authorization — definition and alternate terms

DefinitionPrior authorization (also called preauthorization or precertification) — a process requiring the healthcare provider to obtain advance approval from the plan that an item or service will be covered.

Alternate termsAlso referred to as preauthorization or precertification in this document.

When requiredMedications and services listed in H1036-280 require prior authorization before being provided or administered.

ConsequenceServices or medications provided without required prior authorization may be subject to retrospective medical necessity review and potential financial penalties.

Advance coverage determination (ACD)

Definition

Policy Summary

PayerHumana

PolicyHumana Fully Integrated Florida prior authorization and notification list (HMO D-SNP)

Policy CodePolicy H1036-280

Change TypeAdministrative update — no material clinical or coverage changes

Effective Date07/01/2026

Next Review DateN/A

SourceLink

On This Page

Email: transplant@humana.com

Documentation Required

H1036-280 prior authorization/forms access

Access the fax forms to request preauthorization or provide notification specific to H1036-280 Humana Fully Integrated Florida (HMO D-SNP).

Use the H1036-280 prior authorization and notification fax forms when submitting requests or notifications for this plan.

Prior Authorization

Transplant preauthorization — submission options summarized

Transplant preauthorization requests are reviewed by the Humana National Transplant Network and may be submitted by fax, phone, or email to the network for review.

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

Prior Authorization

Transplant preauthorization submission — fax, phone, email

Preauthorization requests for transplant-related items will be reviewed by the Humana National Transplant Network and can be submitted to that network via multiple channels.

Fax: 502-508-9300
Phone: 866-421-5663, Mon–Fri, 7 a.m.–7 p.m. CT
Email: transplant@humana.com

Step Therapy

Step therapy, new preauth and billing notes

Step therapy is required for some products (denoted **). The product list also identifies new preauthorization requirements and new-to-market drug additions; shared HCPCS/NOC codes require a corresponding NDC on all claims.

** = Step therapy required through a Humana-preferred drug as part of preauthorization
* = New preauthorization requirement
† = New-to-market drug addition
‡ = Shared HCPCS/NOC codes require a corresponding NDC to be billed on all claims

Advance coverage determination (ACD) — a request providers may submit on behalf of a patient to determine if Humana will pay for an investigational/experimental or limited‑benefit service prior to providing it.

How to submitACDs for medications on the list can be initiated by submitting a fax or phone request (per the instructions in the prior authorization list).

PurposeUsed to confirm coverage/payment for investigational, experimental, or limited‑benefit services before care is delivered.

HCPCS/NOC billing requirement

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

ApplicabilityApplies to products in the H1036-280 provider‑administered medication list that use shared HCPCS/NOC codes.

Provider actionInclude the appropriate NDC on claims when billing shared HCPCS/NOC codes to avoid claim denial or processing issues.

Step therapy annotation

Annotation meaning** indicates step therapy is required as part of preauthorization and must follow Humana‑preferred drug sequencing.

ReferencesStep therapy details and preferred drug lists are available on Humana's Part B Step Therapy PDL and related coverage policy pages.

Provider implicationWhen a product is marked **, prior authorization will require documentation that step therapy requirements have been met or an appropriate exception justified.

Document symbols (†, ‡, **, *, ††)

† symbolDenotes a new‑to‑market drug addition in the product list.

‡ symbolIndicates shared HCPCS/NOC codes require a corresponding NDC on claims.

** symbolIndicates the product requires step therapy through a Humana‑preferred drug as part of preauthorization.

* symbolDenotes a new preauthorization requirement has been added for the product.

†† symbolIndicates preauthorization requests will be reviewed by the Humana National Transplant Network (separate submission/review process).

‡ billing note

Billing note (‡)Shared HCPCS and NOC codes require a corresponding NDC to be billed on all claims.

Where shownThis billing requirement is noted throughout the H1036-280 product list where codes are shared among products.

Provider actionAlways include the applicable NDC with shared HCPCS/NOC codes when submitting claims to Humana.

** step therapy

Indicator meaning** indicates step therapy is required through a Humana‑preferred drug and must be satisfied as part of the preauthorization process.

DocumentationPreauthorization submissions for products marked ** must document prior trial and failure (or contraindication) of the Humana‑preferred agent unless an exception is warranted.

Reference materialsHumana's Medicare Part B Step Therapy Preferred Drug List provides additional guidance on preferred agents and cross‑benefit strategies.

† new-to-market

Meaning† denotes a new‑to‑market drug addition to the H1036-280 product list.

ImplicationNew‑to‑market designation signals recent availability and may affect prior authorization handling or clinical review.

ReferenceSee product list annotations in H1036-280 for items marked with †.

* new preauthorization requirement

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

Provider actionFor products newly flagged with *, verify updated submission requirements and include required documentation when requesting preauthorization.

LocationNew preauthorization flags are noted in the H1036-280 product list and accompanying instructions.