H1036-280 Humana Fully Integrated Florida prior authorization and notification list
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Defines medications and related services that require prior authorization or notification for Humana Fully Integrated Florida HMO D-SNP plans and explains how providers should request authorizations; affects participating providers and delegated networks serving Humana MA HMO/HMO POS members in the plan.
No material clinical or coverage changes in this revision.
Prior Authorization and Coverage Criteria
Prior authorization and coverage criteria
Covered when ALL of the following are met:
See drug-specific entries for billing codes and flags.
Refer to CMS coverage guidelines and Humana Medical and Pharmacy Coverage Policies.
See Humana's Medicare Part B Step Therapy Preferred Drug List for details.
Confirm coverage by consulting the patient's Evidence of Coverage or contacting Humana.
This billing requirement applies to codes such as C9399, J3490, J3590, J9999 and other shared HCPCS entries.
Provider submission methods and transplant routing details are specified in the PAL.
Obtain prior authorization before administration to avoid potential adverse payment consequences.
Administrative authorization criteria
Administrative coverage stance and process requirements for listed drugs:
Refer to each drug entry for specific preauthorization or notification instructions and required billing codes.
This applies to shared HCPCS and NOC codes throughout the list (see examples in the PAL).
Review Humana's Part B Step Therapy Preferred Drug List for preferred alternatives and cross‑benefit strategies.
Transplant submission fax: 502-508-9300; phone: 866-421-5663; email: transplant@humana.com (Mon–Fri 7 a.m.–7 p.m. CT).
Prior authorization requirement by drug
Listed drugs require prior authorization or notification as indicated in the H1036-280 prior authorization and notification list. Examples and flags from the list include:
HCPCS, CPT, and Billing Requirements
How Providers Should Request Authorizations and Required Actions
Step therapy and Part B PDL
Prior authorization is required for many medications and services listed on the H1036-280 prior authorization and notification list. Providers must follow the Part B Step Therapy and Part B PDL requirements where applicable, and bill per the authorization annotations and billing notes. Failure to obtain required prior authorization may lead to financial penalties, reduced benefits for the member, or retrospective medical necessity review.
- Step therapy: Some Medicare Part B medications are subject to step therapy; affected medications are noted with a step therapy indicator on the Medicare PAL.
- Part B PDL: Review Humana's Medicare Part B Step Therapy Preferred Drug List (PDL) on Humana's provider prior authorization notification lists website for preferred/nonpreferred listings and cross-benefit strategies.
- Coverage policies: Review Humana's Medical and Pharmacy Coverage Policies in conjunction with the Part B PDL for specific criteria and possible exceptions.
Authorization annotations and billing notes
Authorization annotations and billing notes on the prior authorization list indicate special processing or billing requirements. Providers must follow these annotations when submitting requests or claims to avoid denials or claim reprocessing.
- Legend: * = New preauthorization requirement; † = New-to-market drug addition; ‡ = All shared HCPCS and not otherwise classified 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 routing).
- Billing co-requirements: For codes annotated with ‡, include the corresponding NDC on all claims; follow Humana Medicare Advantage Payment Policy (CP2023011) for required modifiers when applicable.
How to request prior authorization (forms)
How to request prior authorization and access request forms: Prior authorization for medications may be initiated online, by phone, fax, or using Humana’s preauthorization fax forms. For transplant-related preauthorization requests, follow the Humana National Transplant Network routing below.
- Online: Submit requests via CoverMyMeds (http://www.covermymeds.com/).
- Phone: 866-461-7273 (TTY: 711), Monday - Friday, 8 a.m. - 11 p.m., Eastern time; for general provider questions call 800-457-4708 (TTY: 711), daily, 8 a.m. - 8 p.m., Eastern time.
- Fax: 888-447-3430. Request forms are available on Humana's prior authorization for professionally administered drugs webpage; access the H1036-280 fax forms to request preauthorization or provide notification.
- Transplant preauthorization routing: Requests for transplant-related preauthorizations will be reviewed by the Humana National Transplant Network and can be submitted by fax to 502-508-9300, by phone at 866-421-5663, Monday ─ Friday, 7 a.m. ─ 7 p.m., Central time, or by email to transplant@humana.com.
Definitions and Annotation Key
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