Prior authorization required

Prior authorization is required for the medications listed and for certain services. Providers must obtain advance approval from Humana before providing or administering these medications or services. Failure to obtain required prior authorization may result in financial penalties to the practice, retrospective medical necessity review, and denial of payment per the member's Evidence of Coverage and provider contract.

• Prior authorization (preauthorization, precertification) = advance approval from the plan prior to service or medication administration.
• Services must meet Medicare/CMS coverage guidelines and be medically necessary.
• Investigational/experimental procedures and devices are generally not covered.

How to submit prior authorization / ACD for medications

Except where noted in the prior authorization list, providers may submit prior authorization requests or advance coverage determinations (ACDs) for medications using one of the three methods below. CoverMyMeds submissions and fax/phone requests are monitored during stated business hours; include clinical documentation as needed.

• 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 website)

Delegation and applicability

Providers participating in an IPA or other delegated risk network remain subject to Humana's prior authorization list (PAL). Delegated entities should follow their IPA/risk network's instructions for processing requests and may be required to submit requests through delegated workflows.

• Humana MA HMO and HMO POS: full PAL applies.
• Delegated providers: refer to your IPA or risk network for request processing guidance.

Consequences of missing prior authorization

If prior authorization is not obtained when required, services or medications may be denied or result in reduced benefits for the member. Humana may perform retrospective medical necessity review on services provided without prior authorization. Providers should verify benefits and prior authorization requirements prior to providing services to avoid claims payment issues.

• Potential consequences: financial penalties, reduced patient benefits, retrospective medical necessity review, denial of payment.
• To prevent disruption of care, Humana does not require prior authorization for basic Medicare benefits during the first 90 days of a new member’s enrollment for active courses of treatment started prior to enrollment — include modifier per Humana Medicare Advantage Payment Policy or supporting medical records when applicable.

Special indicators and exceptions (legend)

Certain medications and codes on the list are flagged with symbols that indicate special handling or requirements. Review these indicators before submitting a request and ensure required supporting information (such as corresponding NDCs for shared HCPCS codes) is included with claims and authorization 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 for transplant-related items will be reviewed by the Humana National Transplant Network (see transplant submission contacts)

How to request prior authorization and submission contacts

Humana National Transplant Network reviews transplant-related preauthorization requests. Submit transplant requests by fax, phone, or email using the contacts below. For other preauthorization submissions, use the general CoverMyMeds/phone/fax methods listed above. Include NDCs when billing shared HCPCS or NOC codes and follow step therapy requirements where indicated.

• Humana National Transplant Network (transplant products): Fax to 502-508-9300; Phone 866-421-5663, Monday – Friday, 7 a.m. – 7 p.m., Central time; Email: transplant@humana.com
• For non-transplant medication prior authorizations: CoverMyMeds, Phone 866-461-7273 (TTY 711), Fax 888-447-3430
• Include corresponding NDC on claims when using shared HCPCS or NOC codes; failure to include NDCs may affect claim payment.

General preauthorization and billing notes

Operational and billing notes to ensure proper processing and payment: follow Humana coverage and claims payment policies; include required modifiers for active courses of treatment when applicable; comply with step therapy requirements and bill NDCs for shared HCPCS/NOC codes. Access Humana's provider websites for request forms, Part B Step Therapy Preferred Drug List, Medical and Pharmacy Coverage Policies, and specialty/mail-order pharmacy listings.

• Follow Humana's Medicare Advantage Payment Policy (CP2023011) modifier guidance when submitting claims for active courses of treatment started prior to enrollment.
• Step therapy: some medications require trial of Humana-preferred drugs (see Part B Step Therapy PDL on Humana's provider prior authorization notification lists website).
• If providers do not stock a preferred medication, a pharmacy may ship the preferred product to the office; see Humana's mail-order and specialty pharmacy resources.
• Access request forms and fax forms on Humana's prior authorization for professionally administered drugs website.