CurrentHumanaPolicy N/A

Medicare Advantage and D-SNP prior authorization and notification list (medications/services)

Governs prior authorization and notification requirements for medications and certain services for Humana Medicare Advantage and Dual Eligible Special Needs (D-SNP) plans; affects providers submitting requests for members covered by Humana MA and D-SNP plans, with specific notes for plan types and Florida.

Policy Summary

PayerHumana

PolicyMedicare Advantage and D-SNP prior authorization and notification list (medications/services)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization in advance for listed medications; requests may be initiated online via CoverMyMeds, by phone (866-461-7273), or by fax (888-447-3430).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90+medications and biologics listed (partial document)

3ways to initiate prior authorization

90 daysactive treatment exemption (first new-member days)

502-508-9300Transplant Network fax

~40

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blood-clotting factor entries

Medications and Coverage Criteria

Prior authorization and step therapy for Part B medications

Medications on the Humana Medicare Advantage (MA) and Dual Eligible Special Needs (D‑SNP) prior authorization and notification list require prior authorization and may be subject to step therapy and other coverage criteria.

Prior authorization (preauthorization, precertification) must be obtained in advance for medications listed on the MA and D‑SNP PAL.

Some listed medications are subject to step therapy; step therapy requirements are indicated on the PAL and are implemented through Humana's Part B Step Therapy Preferred Drug List (PDL).

Services and medications must meet Medicare/CMS medical necessity criteria and Humana coverage policies to be covered.

Providers must use the specified submission methods (online via CoverMyMeds, phone, or fax) and follow billed-code instructions where provided when requesting prior authorization.

Exceptions

Exceptions and procedural notes apply to specific plan types and to new members in active courses of treatment.

Humana MA private fee‑for‑service (PFFS) plans: prior authorization is not required; notification is requested. Providers may request an advance coverage determination (ACD).

Humana MA HMO, HMO POS, PPO and Florida MA HMO: the full PAL prior authorization requirements apply.

Humana Medicare Supplement Insurance Plan policyholders: this PAL does not apply.

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Medications requiring prior authorization/notification (partial list)

Partial list — the following medications require prior authorization or notification for Humana MA and D‑SNP members; billing codes and symbols indicate special requirements (e.g., step therapy **, NDC billing ‡, transplant review ††, new preauth * ).

Examples (partial list)

belantamab mafodotin‑blmf (Blenrep) — billing codes: C9399, J3490, J3590, J9999; shared HCPCS/NOC rule (‡) may apply.
blinatumomab (Blincyto) — billing code: J9039; prior authorization/notification required.
denosumab‑bnht (Bomyntra/Bosaya) — billing code: Q5158; marked with ** (step therapy) and ‡ (NDC billing) where noted.
bortezomib — billing code: J9046; prior authorization/notification required.

Medication prior authorization/notification entries (excerpt)

Excerpt — medications listed here are subject to prior authorization or notification; providers must access the fax forms to request preauthorization or provide notification.

Glassia (alpha‑1 proteinase inhibitor) — billing codes include J0223, J0257; entry marked with ** where applicable — access fax forms to request preauthorization or provide notification.

Granix (tbo‑filgrastim) — billing code J1447; prior authorization/notification required; use provided fax forms.

Haegarda (C1 esterase inhibitor subcutaneous) — billing code J0599; prior authorization/notification required.

Herceptin (trastuzumab) and related trastuzumab products (Herceptin Hylecta, Hercessi IV, Herzuma) — billing codes include J9355, J9356, Q5146, Q5113; many trastuzumab entries are marked ** (step therapy) — access fax forms for submission.

Prior authorization and billing requirements (partial)

Partial — prior authorization and billing requirements; special instructions and billing considerations apply to listed medications.

Prior authorization or notification is required for the listed drugs; providers must access Humana's fax forms to request preauthorization or provide notification.

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

Transplant‑related items flagged with †† will be reviewed by the Humana National Transplant Network; submissions accepted by fax to 502‑508‑9300, phone at 866‑421‑5663 (Mon–Fri 7 a.m.–7 p.m. CT), or email to transplant@humana.com.

Prior authorization and billing requirements (partial list)

Partial list — medications in this segment require provider action (prior authorization or notification) and include specified billing codes; some are subject to step therapy or NDC billing requirements.

Soliris (eculizumab) — billing codes include J3387 and J1299; entry marked ** (step therapy) where indicated — submit prior authorization via fax/forms.

Spinraza (nusinersen) — billing code J2326; prior authorization/notification required; use provided submission instructions.

Providers must include corresponding NDC when submitting claims for medications billed with shared HCPCS or NOC codes, per the document billing requirement. (‡)

When entries are marked **, follow Humana's step therapy requirements (trial of Humana‑preferred drug) as part of preauthorization.

Prior authorization listing (product-level)

Product‑level prior authorization: listed blood‑clotting factor products require prior authorization using the HCPCS J‑codes shown; entries include flags for new preauthorization, new‑to‑market, step therapy, and NDC requirements where applicable.

Providers must request prior authorization for listed blood‑clotting factor products and use the HCPCS J‑codes shown on the PAL when submitting requests and claims (examples include J7192, J7207, J7210, J7173, J7193, J7201, J7214, J1414).

Document flags: '*' indicates a new preauthorization requirement; '†' indicates new‑to‑market drug additions; '**' indicates step therapy required through a Humana‑preferred drug; '‡' indicates shared HCPCS/NOC codes require a corresponding NDC on claims; '††' indicates the Humana National Transplant Network will review preauthorization requests as noted.

Product examples (partial)

Advate — billing code J7192; marked ‡ where shared HCPCS/NOC NDC rule applies.
Adynovate — billing code J7207.

Billing Codes and Coding Rules

Example medication billing codes listedHCPCS

J9264	Abraxane (paclitaxel-nab) billing code
J3262	Actemra IV (tocilizumab) billing code
Q2055	Abecma (idecabtagene vicleucel) billing code

Examples of billing codes shown in this sectionmixed

C9399	Not otherwise classified drug code (listed for multiple products)
J3490	Unclassified drugs
J3590	Unclassified biologics
J9999	Not otherwise classified, miscellaneous
J9039	Blinatumomab
Q5158	Denosumab-bnht (Q-code)
J9046	Bortezomib

Shared HCPCS / NOC codes with NDC requirementHCPCS | mixed

C9399	Not otherwise classified HCPCS — may require corresponding NDC
J3490	Unclassified drugs — may require corresponding NDC
J3590	Unclassified biologics — may require corresponding NDC

Selected J-codes from listCPT

J2267	Omvoh IV / mirikizumab-mrkz
J9205	Onivyde / irinotecan liposome injection
J0222	Onpattro / patisiran
J9316	Phesgo / pertuzumab, trastuzumab, hyaluronidase-zzxf

Non-J HCPCS codesHCPCS

A9607

Pluvicto / lutetium Lu 177 vipivotide tetraxetan

document-level coding and requirement flagsmixed

‡	Shared HCPCS and NOC codes require a corresponding NDC on all claims
**	Step therapy required through a Humana‑preferred drug as part of preauthorization
††	Preauthorization requests reviewed by the Humana National Transplant Network

blood-clotting factor codesHCPCSCovered

J7192	Advate (antihemophilic factor, human recombinant)
J7207	Adynovate (antihemophilic factor, PEGylated)
J7210	Afstyla (antihemophilic factor, single chain)
J7173	Alhemo (concizumab-mtci)

Selected HCPCS J-codes for blood-clotting factorsHCPCS

J7192	Antihemophilic factor products (used for multiple named products in list)
J7207	Adynovate
J7210	Afstyla
J7205	Eloctate
J7204	Esperoct
J1411	Hemgenix (gene therapy)
J1412	Roctavian (gene therapy)

HCPCS/NDC billing requirement

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

ScopeApplies to shared HCPCS/NOC codes used for medications and biologics listed in the MA and D-SNP prior authorization/notification list.

PurposeEnsures product-level identification on claims when miscellaneous or shared HCPCS/NOC codes are used.

ReferenceDocument symbol: '‡' denotes this NDC billing requirement in the list.

NDC billing requirement

How to Request Prior Authorization and Provider Requirements

Denial Risk

Urgent services and penalties

Urgent or emergent services do not require referrals or prior authorization. Failure to obtain required prior authorization for non‑urgent services may subject the provider and/or member to financial penalties, reduced member benefits, or retrospective medical necessity review. Providers should verify benefits and prior authorization requirements with Humana before providing services to avoid claim denials or recoupment.

Urgent/emergent services: no prior authorization required
Failure to obtain required prior authorization: potential financial penalties and retrospective medical necessity review

Prior Authorization

Plan‑specific requirements

Prior authorization and notification requirements vary by Humana plan type. The full Prior Authorization List (PAL) applies to Humana MA HMO, HMO POS, PPO and Florida MA HMO enrollees. Humana MA PFFS plans do not require prior authorization but notification or an Advance Coverage Determination (ACD) is requested to coordinate care. Providers in delegated arrangements (IPAs or risk networks) must follow their delegation agreement and may submit requests per their network guidance. This list does not apply to Humana Medicare Supplement policyholders.

Definitions and Flag Key

Prior authorization (definition)

DefinitionPrior authorization (preauthorization, precertification) is a process through which the physician or other healthcare provider is required to obtain advance approval from the plan to determine whether an item or service will be covered.

TimingMust be obtained in advance for listed medications/services except where the document notes specific exceptions (e.g., urgent/emergent services).

Initiation methodsPrior authorization may be initiated online via CoverMyMeds, by phone, or by fax as noted in the provider instructions.

HCPCS/NOC NDC billing requirement

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

Symbol

Policy Summary

PayerHumana

PolicyMedicare Advantage and D-SNP prior authorization and notification list (medications/services)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization in advance for listed medications; requests may be initiated online via CoverMyMeds, by phone (866-461-7273), or by fax (888-447-3430).

SourceLink

On This Page

Refer to Humana's provider prior authorization notification lists website and fax forms for the complete list and submission instructions.

Afstyla — billing code J7210.

Eloctate — billing code J7205.

Follow the PAL instructions for submission, billing (include NDC when required), and any step therapy or transplant‑review processes associated with specific products.

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

IndicatorThe document marks this requirement with the symbol '‡' next to affected entries.

Submission impactProviders must include NDC when submitting claims that use shared HCPCS or NOC codes to avoid billing rejections or downstream processing issues.

Related guidanceSee prior authorization instructions for specific billing codes and NDC requirements on listed medications.

Full PAL applies to: MA HMO, HMO POS, PPO, Florida MA HMO
MA PFFS: prior authorization not required; notification/ACD recommended
Delegated providers should follow IPA/risk network processes
Medicare Supplement: PAL does not apply

Prior Authorization

How to request prior authorization (general instructions)

Except where noted for specific items, prior authorization for medications may be initiated via one of the following methods. Use the listed billing codes when submitting requests for the corresponding drugs and include required documentation per Humana submission instructions. All shared HCPCS and not otherwise classified codes require a corresponding NDC on claims.

Online: CoverMyMeds (http://www.covermymeds.com/)
Phone: 866‑461‑7273 (TTY: 711), Mon–Fri, 8 a.m.–11 p.m. Eastern
Fax: 888‑447‑3430 (request forms available on Humana's prior authorization for professionally administered drugs website)
Include corresponding NDC for shared HCPCS/NOC codes on all claims

Prior Authorization

How to request prior authorization (medication examples)

Examples of medications that require prior authorization or notification. Access Humana fax forms to request preauthorization or provide notification and include the billing HCPCS/J‑codes shown when submitting requests.

Blenrep (belantamab mafodotin‑blmf) — Billing Codes: C9399, J3490, J3590, J9999
Blincyto (blinatumomab) — Billing Code: J9039
Bomyntra (denosumab‑bnht) — Billing Code: Q5158
Bortezomib — Billing Code: J9046
Glassia (alpha‑1 proteinase inhibitor) — Billing Codes: J0223, J0257
Granix (tbo‑filgrastim) — Billing Code: J1447
Haegarda (C1 esterase inhibitor, subcutaneous) — Billing Code: J0599
Herceptin (trastuzumab) — Billing Code: J9355
Herceptin Hylecta (trastuzumab + hyaluronidase‑oysk) — Billing Code: J9356

Prior Authorization

Transplant preauthorization submission

Preauthorization requests for transplant‑related drugs and items flagged with †† will be reviewed by the Humana National Transplant Network. Submission methods accepted by the Transplant Network include fax, phone and email; include the HCPCS/J‑codes and supporting clinical documentation when submitting.

Transplant review contact options: Fax 502‑508‑9300
Phone: 866‑421‑5663, Mon–Fri, 7 a.m.–7 p.m. Central
Email: transplant@humana.com
Include HCPCS/J‑codes and clinical documentation with submissions

Prior Authorization

How to request prior authorization (continued medication list)

Additional medication entries require prior authorization or notification. Providers must access Humana's fax request forms for each listed product and submit the corresponding billing codes with the request.

Neupogen (filgrastim) — Billing Code: J2506; alternate filgrastim codes: J1442, Q5110
Nexviazyme (avalglucosidase alfa‑ngpt) — Billing Code: J0219
Ngenla (somatrogon‑ghla) — Billing Codes: C9399, J3490, J3590
Niktimvo IV (axatilimab‑csfr) — Billing Code: J9038
Nivestym (filgrastim‑aafi) — Billing Code: Q5110
Nplate (romiplostim) — see list for billing codes

Prior Authorization

Hyaluronidase‑oscq / Ocrevus Zunovo

For products formulated with hyaluronidase or specific biosimilar presentations, such as hyaluronidase‑oscq and Ocrevus Zunovo, providers must use the listed billing code and submit prior authorization or notification via Humana's fax request forms. Verify whether step therapy or other special requirements apply.

Ocrevus Zunovo — Billing Code: J2351
Hyaluronidase‑oscq — follow product‑specific submission instructions
Check for step therapy (**), new‑to‑market (†), or transplant (††) flags on each line item

Documentation Required

Drug‑specific prior authorization instructions (examples)

Drug‑specific prior authorization instructions: when a drug entry lists HCPCS or J‑codes, include those codes on the preauthorization request and on claims. For shared HCPCS or NOC codes, always include the corresponding NDC on the claim. Products marked with ** require step therapy through a Humana‑preferred drug as part of the prior authorization process.

Use the exact HCPCS/J‑codes listed for each medication when requesting prior authorization
Include corresponding NDC on claims for shared HCPCS/NOC codes
Products marked **: step therapy through a Humana‑preferred drug is required
Products marked †: new‑to‑market additions; ††: transplant review required

Note

How to request prior authorization (summary and submission resources)

Summary reminders and submission resources: use CoverMyMeds, phone, or fax to submit requests (see contact details). Include the billing codes shown in the PAL entries, attach supporting clinical documentation, and for transplant‑flagged items submit to the Humana National Transplant Network via fax, phone or email. Failure to follow these submission methods or to include required codes and NDCs may delay determination or result in retrospective review.

Submission options: CoverMyMeds, 866‑461‑7273 (TTY 711), or fax 888‑447‑3430
Transplant Network: fax 502‑508‑9300, phone 866‑421‑5663, email transplant@humana.com
Always include HCPCS/J‑codes and corresponding NDCs when applicable
Attach clinical documentation to support medical necessity

Marked with '‡' in the document wherever this billing rule applies.

ApplicabilityApplies across the MA and D-SNP prior authorization list where C9399, J3490, J3590 or other NOC/shared HCPCS codes are used.

Step therapy indicator

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

ImplicationEntries marked with ** require trial and failure (or documentation of contraindication) of a Humana-preferred agent before coverage of the listed product may be authorized.

LocationThe '**' flag is used throughout the MA and D-SNP prior authorization/notification list next to affected medications.

Transplant review process

ProcessPreauthorization requests for certain products will be reviewed by the Humana National Transplant Network.

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

FlagTransplant-review items are indicated by the symbol '††' in the document.

New-to-market indicator

Flag† indicates a new-to-market drug addition.

UsageUsed in the prior authorization list to denote products newly added to market that may have distinct review considerations.

ReferenceSee document legend where symbols (*, †, ‡, **, ††) are defined for interpretation of entries.

Step therapy required through a Humana-preferred drug

MeaningStep therapy required through a Humana-preferred drug (denoted by '**').

ExamplesSeveral immune modulators and injectables in the list are annotated with '**' indicating step therapy applies.

Action for providersDocument trial and failure of preferred Humana agent or provide contraindication information when submitting preauthorization.

* indicates a new preauthorization requirement

Meaning'*' indicates a new preauthorization requirement added to the list.

ImplicationProducts marked with '*' are newly subject to prior authorization as of the effective/revision dates noted.

ReferenceSee the legend and entry context in the prior authorization list for specifics about new requirements.

† indicates new-to-market drug addition

Meaning† indicates a new-to-market drug addition.

ContextUsed in the document legend to flag entries that represent newly marketed products.

Provider noteNew-to-market entries may require additional documentation or have special review pathways; follow the listed instructions.

‡ indicates shared HCPCS codes/NOC codes requiring NDC on claims

Meaning‡ indicates shared HCPCS codes and not otherwise classified (NOC) codes that require a corresponding NDC to be billed on claims.

ImplicationWhen an entry shows '‡', providers must include the NDC on the claim to meet Humana's billing requirement.

Document usageThis flag appears repeatedly in the MA and D-SNP prior authorization/notification list next to affected products and codes.

Special flags

* (new preauth)'*' indicates a new preauthorization requirement; see document legend.

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

Usage noteUse these flags to interpret individual medication entries in the prior authorization list.

Shared HCPCS/NOC coding requires corresponding NDC on claims

RequirementShared HCPCS and not otherwise classified (NOC) codes require a corresponding NDC to be billed on claims (document symbol: '‡').

ExamplesApplies to entries using codes such as C9399, J3490, J3590 where product-level identification is necessary.

Provider actionInclude the NDC on claim submissions when billing these shared HCPCS/NOC codes to avoid claim issues.

Step therapy required through a Humana‑preferred drug as part of preauthorization

Indicator** denotes that step therapy through a Humana-preferred drug is required as part of the preauthorization process.

EffectPreauthorization may be denied or additional documentation required if step therapy requirements are not met.

DocumentationWhen submitting preauthorization, show evidence of trial of Humana-preferred agent or clinical rationale for bypassing step therapy.

Preauthorization requests reviewed by the Humana National Transplant Network

Flag†† indicates that preauthorization requests will be reviewed by the Humana National Transplant Network.

Submission channelsFax: 502-508-9300; Phone: 866-421-5663 (Mon–Fri 7 a.m.–7 p.m. CT); Email: transplant@humana.com.

When usedAppears next to transplant-related product entries in the prior authorization/notification list.

NDC requirement for shared HCPCS/NOC codes

RequirementShared HCPCS codes and not-otherwise-classified (NOC) codes require a corresponding NDC to be billed on all claims.

Document flagDenoted by '‡' throughout the prior authorization list.

Provider noteEnsure the NDC is present on claims when billing using shared HCPCS/NOC codes to comply with Humana billing rules.

Step therapy flag (**)

Flag definitionEntries marked with '**' indicate a product subject to step therapy through a Humana-preferred drug as part of preauthorization.

Provider implicationProviders must document prior use of preferred agents or rationale for exceptions when requesting authorization for '**' items.

LocationFlag used consistently across the MA and D-SNP prior authorization list to signal step therapy requirements.

New product/preauthorization flags

† flagEntries marked with '†' indicate new-to-market drug additions.

* flag'*' indicates a new preauthorization requirement for that product.

GuidanceReview entry context and effective/revision dates for implications on prior authorization procedures.