CurrentHumanaPolicy N/A

Humana Dual Integrated South Carolina prior authorization and notification list

Defines prior authorization and notification requirements for medications (professionally administered/in-office, outpatient, home) and related services for Humana Dual Integrated (HMO D-SNP) members in South Carolina; affects participating providers, facilities, and delegated networks.

Policy Summary

PayerHumana

PolicyHumana Dual Integrated South Carolina prior authorization and notification list

Policy CodePolicy N/A

Change TypeMinor / no material coverage changes

Effective DateJul 1, 202610d

Next Review DateN/A

Key ActionInitiate prior authorization requests via CoverMyMeds online, phone 866-461-7273 (TTY:711) Mon–Fri 8a–11p ET, or fax 888-447-3430.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3ways to initiate prior authorization

90 daystemporary PA waiver (new members)

866-461-7273PA phone

888-447-3430PA fax

National Transplant Networktransplant reviewer

Coverage and Product Listings

High-level coverage criteria and procedures

Covered when ALL of the following administrative and program requirements are met:

Medications and services must meet Medicare/CMS coverage guidelines and be medically necessary as defined by CMS

See CMS coverage guidelines and Humana Medical and Pharmacy Coverage Policies for details.

Medications delivered in a provider office, clinic, outpatient or home setting listed on this document require prior authorization before administration

Prior authorization is defined as advance approval from the plan that an item or service will be covered.

Investigational or experimental procedures/devices are generally not covered; consult the member's Evidence of Coverage or Humana to confirm coverage

Advance coverage determination (ACD) is available for investigational/limited benefit services and certain medication requests

ACD requests can be initiated via the usual PA submission methods (phone, fax, CoverMyMeds).

Step therapy requirements may apply to Medicare Part B medications; review Humana's Part B Step Therapy Preferred Drug List for specific criteria and cross-benefit strategies

All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on claims where indicated (marked '‡')

Urgent or emergent services do not require prior authorization

Providers should include required administrative information when submitting an authorization request, including up to 6 diagnosis codes per request

Drug/Code listings and PA/notification flags (partial)

Medication entries list brand name, generic name, and associated billing codes; annotations signal special processing requirements:

Each listed drug entry includes: 1 = generic medication name; 2 = billing codes (HCPCS/J-, Q-, or A- codes)

Entries may be annotated with special flags: '*' = new preauthorization requirement; '†' = new-to-market drug addition; '‡' = shared HCPCS/NOC code requiring an NDC on claims; '**' = step therapy required; '††' = routed to Humana National Transplant Network for review

Where an entry is marked with '‡', providers must include the corresponding NDC on claims for billing accuracy

Listing format and annotations

Listing format and annotation conventions used throughout the product list:

Format for each listing: Brand name, optional flag(s), therapeutic category; 1 = generic medication name; 2 = billing code(s)

Flag conventions: '*' = new preauthorization requirement; '†' = new-to-market addition; '‡' = shared HCPCS/NOC code requiring an NDC; '**' = step therapy required through Humana-preferred drug; '††' = transplant review routing to Humana National Transplant Network

The presence of '**' indicates a step therapy requirement that must be met as part of prior authorization review

Prior authorization — product list (no clinical criteria in these chunks)

The following products (examples shown) require prior authorization; HCPCS billing codes accompany each listing. Flags shown in the list indicate additional billing or review requirements.

Examples (blood‑clotting factors)

Advate — antihemophilic factor, human recombinant — J7192
Adynovate — antihemophilic factor (recombinant), PEGylated — J7207
Afstyla — antihemophilic factor (recombinant) single chain — J7210
Hemlibra ** — emicizumab-kxwh — J7170 (marked '**' indicates step therapy)
Kogenate FS ‡ — antihemophilic factor (recombinant) — J7192 (marked '‡' requires NDC on claims)

Billing Codes and Mappings

Sample medication billing codes (partial list)HCPCS

Q2055	Abecma intravenous suspension
J9264	Abraxane (paclitaxel-nab)
J3262	Actemra IV (tocilizumab)

Additional medication billing codes (partial)HCPCS

J9035	Avastin (bevacizumab) — auth only for oncology/chemo use
J3145	Aveed (testosterone undecanoate)
Q5121	Avsola (infliximab biosimilar)

Example drug-to-billing-code mappings (partial list)HCPCS

J0178	Aflibercept (Eylea)
J1428	Eteplirsen (Exondys 51)
J3111	Romosozumab-aqqg (Evenity)

Examples of J-codes present in listHCPCS

J9316	Phesgo (trastuzumab and hyaluronidase-zzxf) billing code
J1745	Remicade (infliximab) billing code
J0897	Prolia / Xgeva (denosumab) billing code

Listed HCPCS J-codes for blood-clotting factorsHCPCS

J7192	Used for several antihemophilic factor products (examples: Advate, Kogenate FS, Recombinate)
J7207	Adynovate (antihemophilic factor [recombinant], PEGylated)
J7210	Afstyla (antihemophilic factor [recombinant] single chain)
J7173	Alhemo (concizumab-mtci)
J7186	Alphanate (antihemophilic factor/von Willebrand factor complex [human])
J7193	AlphaNine SD (coagulation factor IX [human])
J7201	Alprolix (coagulation factor IX [recombinant])
J7214	Altuviiio (efanesoctocog alfa)
J1414	Beqvez (fidanacogene elaparvovec-dzkt)
J7175	Coagadex (coagulation factor X [human])

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Coding threshold

Maximum diagnosis codes per authorization request6

Information required (diagnosis codes)Include primary and secondary diagnosis codes up to the maximum per request

PurposeUsed for prior authorization determination and claim processing

How to Request Authorization and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Humana requires prior authorization for certain medications and services listed in this document. Prior authorization (also called preauthorization or precertification) is the process by which the provider must obtain advance approval from Humana to determine whether an item or service will be covered. Services provided without required prior authorization may be subject to retrospective medical necessity review and potential denial or financial penalties. Providers should submit all relevant clinical information with the request to expedite determination.

Prior authorization applies to medications administered in-office, outpatient, or home settings.
Failure to obtain required prior authorization may result in claim denials or reduced payment and retrospective review.

Note

How to Request Prior Authorization / ACD

To request prior authorization or an advance coverage determination (ACD) for medications, providers may use one of the following methods unless otherwise noted for specific drugs:

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)
ACDs for medications may also be initiated by phone at 866-461-7273 or fax to 888-447-3430. Include all relevant clinical information to prevent delays.

Note

Urgent Care and Delegated Network Note

Urgent or emergent services do not require prior authorization. Providers participating in delegated risk networks or independent practice associations (IPAs) should follow their IPA or network guidance for authorization processing; however, the full prior authorization requirements still apply and may be enforced by Humana. If services are delegated, verify whether the IPA or delegated entity will handle the request or if submission to Humana is required.

Urgent/emergent services: no prior authorization required.
Delegated network/IPA providers: follow the IPA/network process and confirm routing for PA requests.

Step Therapy

Step Therapy Guidance

Humana's step therapy program applies to certain Medicare Part B medications and may require trial of a Humana-preferred drug before approval of the requested medication. Providers should consult Humana's Medicare Part B Step Therapy Preferred Drug List (PDL) for preferred and nonpreferred medications, including cross-benefit strategies that may span Part B and Part D. The preferred status does not guarantee exemption from step therapy; review specific coverage criteria and step therapy indicators on the Medicare PAL.

Step therapy indicators are noted on the Medicare prior authorization list.
If a provider does not stock a preferred medication, a pharmacy may supply it (see Humana's specialty and mail-order pharmacy listings).
Step therapy may require cross-benefit trials (Part B vs Part D) — see the Part B Step Therapy PDL for details.

Note

Transplant Preauthorization Routing

Certain preauthorization requests for transplant-related services and therapies will be routed to the Humana National Transplant Network for review. Providers should submit these transplant preauthorization requests using the transplant-specific contact methods.

Transplant preauthorization routing: requests reviewed by Humana National Transplant Network.
Transplant submission contacts: fax 502-508-9300; phone 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. Central); email transplant@humana.com.

Billing Rule

Prior Authorization Qualifiers and Billing Requirements

Prior authorization qualifiers and billing requirements: Humana may add new preauthorization requirements or step therapy requirements throughout the year. All shared HCPCS and not otherwise classified (NOC/C9399/J3490/J3590) codes billed for medications require a corresponding National Drug Code (NDC) on the claim. Providers must ensure claims include the correct NDC when using shared HCPCS/NOC codes to avoid claim denials.

New preauthorization requirements and step therapy additions may be implemented during the year — check Humana's provider prior authorization notification lists website for updates.
All shared HCPCS and NOC codes (including C9399, J3490, J3590) require the corresponding NDC on the claim.
Failure to include the NDC for shared HCPCS/NOC codes may result in claim payment issues or denials.

Flags and Term Definitions

Prior authorization (definition)

DefinitionPrior authorization is a process through which the healthcare provider is required to obtain advance approval from the plan as to whether an item or service will be covered.

Applies toMedications delivered in provider office, clinic, outpatient or home settings listed on the document

Related guidanceServices must follow Medicare/CMS coverage guidelines and Humana coverage policies

Part B Step Therapy PDL (definition)

NamePart B Step Therapy Preferred Drug List (PDL)

PurposeDesignates preferred and nonpreferred medications and describes cross-benefit step therapy strategies for Medicare Part B medications

Action for providersReview Humana's Part B Step Therapy PDL alongside Humana coverage policies when step therapy indicators appear on the Medicare PAL

HCPCS / NOC NDC billing requirement (‡)

Symbol‡

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

Provider actionEnsure the corresponding NDC is included on claims for items marked with ‡

Step therapy flag (**)

Symbol**

MeaningStep therapy required through a Humana-preferred drug as part of preauthorization

Provider actionConfirm whether a trial of a preferred medication is required per Humana's Part B Step Therapy PDL when ** is present

Transplant review flag (††)

Symbol††

MeaningPreauthorization requests for items marked with †† will be reviewed by the Humana National Transplant Network

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

New preauthorization / new-to-market markers (*, †)

Symbols* and †

Meaning'*' indicates a new preauthorization requirement; '†' indicates a new-to-market drug addition

Provider actionNote change markers on the listing to identify newly added preauthorization requirements or new-to-market products

‡ (NDC billing requirement)

Symbol‡

Meaning (explicit)'‡' indicates shared HCPCS or not otherwise classified codes that require a corresponding NDC on claims

Repeated noteMultiple chunks reiterate that shared HCPCS/NOC codes marked with ‡ must include an NDC on all claims

** (step therapy)

Symbol**

MeaningIndicates step therapy is required through a Humana-preferred drug as part of preauthorization

Provider actionRefer to Humana's Part B Step Therapy PDL for trial and preferred-drug details when ** appears

‡ (billing note duplicate)

Symbol‡

MeaningIndicates shared HCPCS codes and NOC codes require an NDC on all claims

InstructionEnsure NDC presence on claim submissions for items marked with ‡ to avoid claim processing issues

** (step therapy duplicate)

Symbol**

MeaningDenotes step therapy requirement through a Humana-preferred drug as part of preauthorization

ActionFollow Part B Step Therapy PDL and document trials of preferred medications where required

* / † (change markers)

Symbols* and †

Definitions'*' = new preauthorization requirement; '†' = new-to-market drug addition

Provider implicationWatch listings for these markers to identify policy changes affecting authorization needs

†† (transplant review note duplicate)

Symbol††

MeaningIndicates preauthorization requests will be reviewed by the Humana National Transplant Network with provided contact methods

Contact detailsFax 502-508-9300; phone 866-421-5663 (M–F 7 a.m.–7 p.m. CT); email transplant@humana.com

Policy Summary

PayerHumana

PolicyHumana Dual Integrated South Carolina prior authorization and notification list

Policy CodePolicy N/A

Change TypeMinor / no material coverage changes

Effective DateJul 1, 202610d

Next Review DateN/A

Key ActionInitiate prior authorization requests via CoverMyMeds online, phone 866-461-7273 (TTY:711) Mon–Fri 8a–11p ET, or fax 888-447-3430.

SourceLink

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