CurrentHumanaPolicy N/A

Medicare Advantage and D-SNP prior authorization and notification list for medications (Part 1)

Governance of prior authorization (PA) and notification requirements for medications administered in-office, outpatient, clinic or home settings for Humana Medicare Advantage and Dual Eligible Special Needs Plans; guidance for providers on how to request PA and required information. This brief covers content present in Part 1 of the full document.

Policy Summary

PayerHumana

PolicyMedicare Advantage and D-SNP prior authorization and notification list for medications (Part 1)

Policy CodePolicy N/A

Change TypeUpdate to PA/notification list

Effective Date07/01/2026

Next Review DateN/A

Key ActionProviders must obtain prior authorization for medications listed on the MA and D-SNP Medication Prior Authorization and Notification List before providing or administering those medications, using the specified online, phone or fax submission methods and including required clinical and billing details.

SourceLink

07/01/2026Effective date (document)

multipleMedications listed requiring prior authorization (partial list shown)

Online/Phone/FaxAccepted submission methods for medication PA

‡Shared HCPCS/NOC codes require NDC on claims

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Policy Snapshot & Scope

This document establishes Humana's requirements for prior authorization and notification for medications administered in office, outpatient, clinic or home settings for Medicare Advantage (MA) and Dual-Eligible Special Needs Plan (D-SNP) members. It governs requests and submissions for medications listed on the MA and D‑SNP Medication Prior Authorization and Notification List and sets expectations for documentation, billing and review. The policy is effective 07/01/2026 and the overall coverage stance is covered_with_criteria — medications on the list may be covered if the plan's prior authorization criteria and Medicare coverage guidelines are satisfied.

Prior Authorization & Coverage Requirements

Providers must obtain prior authorization for medications listed on the MA and D‑SNP Medication Prior Authorization and Notification List before providing or administering those drugs for Humana MA and D‑SNP members, including in-office, outpatient, clinic or home administration. Exceptions include services that are urgent/emergent (which do not require PA), patients enrolled in MA private fee‑for‑service (MA PFFS) plans (PA is not required for PFFS but an advance coverage determination/notification may be requested), and the first 90 days of a new member's enrollment for active courses of treatment started prior to enrollment where Humana does not require PA to prevent disruption of care.

Billing Codes & HCPCS/NDC Requirements

Examples of medication billing HCPCS/Codes referenced in Part 1HCPCS|CPT|mixedCovered

Q2055	Abecma (idecabtagene vicleucel) - billing code noted
J9264	Abraxane (paclitaxel-nab)
J3262	Actemra IV (tocilizumab)
J0791	Adakveo (crizanlizumab-tmca)
J9042	Adcetris (brentuximab vedotin)
J9029	Adstiladrin
J0172	Aduhelm (aducanumab-avwa)
J7171	Adzynma (ADAMTS13, recombinant-krhn)
J1454	Akynzeo IV (fosnetupitant and palonosetron)
J1931	Aldurazyme (laronidase)

1–10 of 78

1/8

Drugs and associated billing codes (partial list — extracted from this segment)HCPCS|CPT

C9399	Not otherwise classified drug/biological (used for multiple listed products)
J3490	Unclassified drugs (used for multiple listed products)
J0589	daxibotulinumtoxinA-lanm (Daxxify)
J9172	docetaxel (Docivyx)
Q2050	doxorubicin HCL liposome injection (Doxil)
J0586	abobotulinumtoxin A (Dysport)
J9063	mirvetuximab soravtansine-gynx (Elahere)
J1743	idursulfase (Elaprase)
J3060	elezan ??? (partial text present) — code listed in text
J1413	delandistrogene moxeparvovec-rokl (Elevidys)

1–10 of 62

1/7

Medication billing codes referenced in this partmixed

J0641	levoleucovorin calcium
J9119	cemiplimab-rwlc (Libtayo)
C9399	Not otherwise classified HCPCS - used with NDC per notes
J3490	Unclassified drugs
J3590	Unclassified biologics
J3263	toripalimab-tpzi (Loqtorzi)
J2778	ranibizumab (Lucentis)
J0221	alglucosidase alfa (Lumizyme)
J9350	mosunetuzumab-axgb (Lunsumio)
A9513	lutetium Lu 177 dotatate (Lutathera)

1–10 of 35

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Billing Rule

NDC required when billing shared HCPCS / NOC codes

All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims. Examples called out in the policy include C9399, J3490, J3590 and other listed shared/NOC codes; when those codes are used on a claim the product NDC must be included.

Policy statement: “All shared HCPCS codes and not otherwise classified codes require a corresponding National Drug Code (NDC) to be billed on all claims.”
Examples in the drug list show many entries billed with C9399/J3490/J3590 and marked with ‡ indicating the NDC requirement.
Repeated notes throughout the list reiterate the NDC-on-claims requirement for shared/NOC codes.

Documentation Required

HCPCS / NDC billing requirement note

Humana requires that all shared HCPCS codes and not otherwise classified (NOC) codes be submitted with the product's NDC on the claim; this requirement is reiterated multiple times in the list (entries flagged with ‡).

Definition/term: “All shared HCPCS codes and not otherwise classified codes require a corresponding National Drug Code (NDC) to be billed on all claims.”
The drug listing uses the ‡ annotation to indicate codes that require an NDC on the claim.

What Providers Must Do

Prior Authorization

When prior authorization is required

Providers must obtain prior authorization for medications listed on the MA and D‑SNP Medication Prior Authorization and Notification List before providing/administrating medications in office, outpatient, clinic or home settings, except where noted.

Failure to obtain PA may result in financial penalties, reduced member benefits, or retrospective medical necessity review.

Prior Authorization

How to submit prior authorization requests (medications)

Prior authorization for medications may be submitted online via CoverMyMeds, by phone, or by fax. Humana provides specific contact details and hours for submission.

Online: CoverMyMeds (http://www.covermymeds.com/).
Phone: 866-461-7273 (TTY: 711), Monday–Friday, 8 a.m.–11 p.m. ET.
Fax: 888-447-3430 (request forms available on Humana's prior authorization for professionally administered drugs website).

Submission Paths, Forms & Exceptions

Humana directs providers to use the referenced Humana fax forms for many products when requesting prior authorization or providing notification; these forms are available via Humana's prior authorization for professionally administered drugs website. Preauthorization for most listed medications may be initiated online through CoverMyMeds, by phone at 866-461-7273 (TTY: 711) Monday–Friday 8 a.m.–11 p.m. ET, or by fax to 888-447-3430. Transplant- and certain cell‑ or gene‑therapy requests flagged for the Humana National Transplant Network require special routing and may be submitted to fax 502-508-9300, phone 866-421-5663 (Mon–Fri 7 a.m.–7 p.m. CT) or email transplant@humana.com. As noted in the guidance, MA PFFS plans do not require PA but an advance coverage determination (ACD) can be requested using the same phone/fax contacts when appropriate.

Documentation Required

Documentation to expedite PA determination

To expedite determination, include all relevant clinical documentation and the following data elements with the PA/notification request.

Patient name, DOB and Humana member ID
Date of service/admission
HCPCS and diagnosis codes (up to 6)
Service location and facility/provider TIN and NPI
Caller/requester and attending physician contact info
Relevant clinical information and supporting documentation

Key Terms & Symbols

Definitions

Prior authorizationA process through which the physician or other healthcare provider is required to obtain advance approval from the plan as to whether an item or service will be covered (also referred to as preauthorization or precertification).

MAMedicare Advantage

MA PFFSMedicare Advantage private fee-for-service plan; PA not required but notification or ACD may be requested.

D-SNPDual-Eligible Special Needs Plan

‡Indicates shared HCPCS or NOC codes that require a corresponding NDC on claims. All shared HCPCS codes and not otherwise classified codes require a corresponding National Drug Code to be billed on all claims.

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

Context & Rationale

This Medication Prior Authorization and Notification List supports Humana's administrative oversight of Part B medications administered across care settings for MA and D‑SNP members. The list identifies drugs that require advance review so coverage can be determined consistent with Medicare guidelines and Humana policy. It also establishes billing requirements and governance (for example, many shared HCPCS and NOC codes require a corresponding NDC on claims) and identifies that some products are subject to step therapy, transplant‑network review or other program annotations noted on the list.

Policy Dates & Changes

07/01/2026EffectiveLatest

Policy effective date as listed for the Humana Medicare Advantage and D-SNP prior authorization and notification list.