CurrentHumanaPolicy N/A

Prior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia

Governs prior authorization and notification requirements for medications and certain services for Humana Dual Fully Integrated (HMO D-SNP) Virginia plans; affects participating providers delivering office/clinic/outpatient/home-administered medications and related services.

Policy Summary

PayerHumana

PolicyPrior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia

Policy CodePolicy N/A

Change TypeAdministrative update (no material changes)

Effective DateJul 1, 202618d

Next Review DateN/A

Key ActionInitiate prior authorization requests via CoverMyMeds, phone at 866-461-7273, or fax to 888-447-3430 and include required clinical and billing documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-461-7273phone to initiate authorizations

888-447-3430fax to submit authorizations

VAapplicable state

20+medications in excerpt

866-421-5663transplant review contact

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

90 daysno prior auth required (active tx)

Coverage and Authorization Requirements

General coverage stance

Coverage requires medical necessity and adherence to Medicare/CMS guidelines; investigational or experimental procedures/devices are generally not covered.

ALL of the following

Service or medication must be medically necessary and provided according to Medicare/CMS coverage guidelines (refer to CMS).
Prior authorization is required for medications listed in this document when delivered in the provider's office, clinic, outpatient or home setting; providers must obtain advance approval from the plan to determine coverage.
Investigational and experimental procedures and devices usually are not covered; consult the member's Evidence of Coverage or Humana for confirmation of coverage.

Refer to Humana's Medical and Pharmacy Coverage Policies for detailed coverage criteria and to Humana's provider prior authorization notification lists website for the Part B Step Therapy Preferred Drug List (where applicable).

Prior authorization / notification medication list (partial)

Partial extract of the prior authorization/notification medication list; entries below show medication name, generic equivalent and associated billing code(s).

Examples from the partial list

fulvestrant (Fresenious kabi) — J9394
Herceptin (trastuzumab) — J9355
Lucentis (ranibizumab) — J2778

This is a partial extract (chunks 36–52) of a larger prior authorization list; consult the full Humana prior authorization and notification list for the complete set of medications and codes.

Medications requiring prior authorization/notification (partial list)

Partial entries illustrating medications that require prior authorization/notification and notation conventions (see operational notes for symbols).

Partial medication entries

Monoferric (ferric derisomaltose) — J1437 — flagged with ** (step therapy).
Mozobil (plerixafor) — J2562 — flagged with ‡ (NDC required).
Neupogen (filgrastim) — J1442 — flagged with ** (step therapy).
Ngenla — billing codes include C9399, J3490, J3590 (multiple/NOC codes).

Access the fax forms to request prior authorization or provide notification for listed medications; medication entries include brand, generic name and billing code(s).

Prior authorization/notification medication list (partial)

Additional partial list entries; some medications are annotated for step therapy, NDC billing requirements, or transplant review.

Sample entries and annotations

Sajazir (icatibant) — J1744 — flagged with ‡ (NDC required).
Selarsdi IV (ustekinumab-aekn) — Q9998/J7352 — flagged with ** and ‡ (step therapy and NDC required).
Skysona (elivaldogene autotemcel) — J3387 — flagged with †† (transplant review).

Symbols used in the list: * = new preauthorization requirement; † = new-to-market; ‡ = shared HCPCS/NOC codes require corresponding NDC on claims; ** = step therapy required through a Humana-preferred drug; †† = transplant-reviewed items (special submission instructions).

Operational and billing criteria

Operational and billing rules that apply to entries in the prior authorization/notification list.

ALL of the following

All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims (‡).
Items flagged with '**' require step therapy through a Humana-preferred drug as part of preauthorization.
Items flagged with '††' are reviewed by the Humana National Transplant Network; transplant preauthorization requests 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.

Providers must include required documentation on prior authorization requests (patient identifiers, service date, HCPCS and diagnosis codes — up to 6 — service location, TIN/NPI, caller information, and relevant clinical information) and follow Humana's submission channels (CoverMyMeds, phone, fax).

Billing Codes and Coding Rules

Sample HCPCS/J-codes from medication listHCPCS

Q2055	Abecma billing code as listed
J9264	Abraxane billing code as listed
J3262	Actemra IV billing code as listed

Sample medication billing codesmixed

J1551	Cutaquig billing code listed
J1555	Cuvitru billing code listed
J9308	Cyramza billing code listed

Additional billing codesmixed

J9301	Gazyva billing code listed
J7326	Gel-One billing code listed

Sample HCPCS/J-codes listedHCPCS

J9394	fulvestrant (Fresenius kabi)
J9393	fulvestrant (Teva)
J9355	trastuzumab (Herceptin IV)
J2778	ranibizumab (Lucentis)

Additional HCPCS/J-codes (partial)HCPCS

J0174	lecanemab-irmb (Leqembi)
J1306	inclisiran (Leqvio)
J1437	ferric derisomaltose (Monoferric)

Example medication billing codes (partial list)HCPCS

J9349	Monoferric
J1437	Mozobil (plerixafor)
J2562	plerixafor
Q5107	Mvasi (bevacizumab-awwb)
J9203	Mylotarg (gemtuzumab ozogamicin)
J0587	Myobloc (rimabotulinumtoxinB)

Additional medication billing codes (partial list)HCPCS

J9299	Opdivo (nivolumab) — example not otherwise classified
J9289	Opdivo Qvantig (nivolumab hyaluronidase-nvhy)
J9318	romidepsin

sample medication billing codes in this segmentHCPCS | CPT

J1744	billing code listed for icatibant / Sajazir
J2353	billing code listed for octreotide (Sandostatin LAR)
J0491	billing code listed for anifrolumab-fnia (Saphnelo IV)
J9227	billing code listed for isatuximab-irfc (Sarclisa)
J7352	billing code listed (Selarsdi IV)
Q9998	billing code listed (Selarsdi IV)

Sample HCPCS/J/Q codes in excerptmixed

C9399	Not otherwise classified HCPCS code listed for multiple products
J3490	Not otherwise classified J-code listed for multiple products
Q5138	Q-code listed for Wezlana IV (ustekinumab-auub)
Q5136	Q-code listed for Wyost (denosumab-bbdz)
J1558	J-code listed for Xembify (immune globulin)

Blood-clotting factors codesmixed

J7192	Used for several antihemophilic factor entries
J7207	Adynovate billing code
J7210	Afstyla billing code
J7173	Alhemo billing code
J1414	Beqvez billing code (gene therapy)

inv-16: Diagnosis/HCPCS code limits

Diagnosis code limitMaximum of 6 diagnosis codes per prior authorization request

Use on request formInclude up to 6 relevant diagnosis codes when submitting authorization

ReferenceSee 'Information required for a prior authorization request' and coding thresholds in the list

inv-17: NDC requirement for shared HCPCS/NOC codes

NDC requirement (‡)

How Providers Request Authorization & Submission Channels

Prior Authorization

How to request prior authorization

Prior authorization is required for listed medications administered in provider/clinic/outpatient/home settings. Requests may be initiated via CoverMyMeds, by phone at 866-461-7273 (TTY: 711), or by fax at 888-447-3430; request forms are available on Humana's prior authorization for professionally administered drugs website.

Online: CoverMyMeds
Phone: 866-461-7273 (TTY: 711), Mon–Fri, 8 a.m.–11 p.m. ET
Fax: 888-447-3430 (request forms on Humana website)

Denial Risk

Denial risk / financial penalty

Failure to obtain required prior authorization may result in financial penalties to the practice and reduced benefits for the patient; services or medications provided without prior authorization may be subject to retrospective medical necessity review.

Definitions and Annotation Keys

inv-35: prior authorization

Prior authorization requiredPrior authorization is required for medications delivered in the provider's office, clinic, outpatient, or home setting as listed in this document.

How to initiateRequests may be initiated via CoverMyMeds, phone (866-461-7273), or fax (888-447-3430); access fax forms referenced in the list.

ConsequencesFailure to obtain prior authorization may result in financial penalties and retrospective medical necessity review.

inv-36: medications on the list

Scope of listMedications enumerated throughout the document require prior authorization or notification and include brand/generic names and billing codes.

ExamplesExamples in the list include fulvestrant (J9394), trastuzumab (J9355), ranibizumab (J2778), and many others across sections.

Policy Summary

PayerHumana

PolicyPrior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia

Policy CodePolicy N/A

Change TypeAdministrative update (no material changes)

Effective DateJul 1, 202618d

Next Review DateN/A

Key ActionInitiate prior authorization requests via CoverMyMeds, phone at 866-461-7273, or fax to 888-447-3430 and include required clinical and billing documentation.

SourceLink

On This Page

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

When it appliesApplies to items annotated with the '‡' symbol throughout the prior authorization list

Billing implicationClaims without the corresponding NDC for shared HCPCS/NOC codes may be noncompliant with billing requirements

inv-18: NDC requirement for shared HCPCS/NOC codes (duplicate index)

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

Location in documentNotations and operational notes reiterate the NDC requirement in multiple sections of the list

Provider actionEnsure corresponding NDC is included on claim when billing shared HCPCS/NOC codes

Penalties and reduced member benefits may apply per provider contract and member Evidence of Coverage
Services provided without authorization may be reviewed retrospectively for medical necessity

Documentation Required

Required documentation for prior authorization request

Include the following information when submitting a prior authorization request: patient identifiers, date of service, HCPCS codes and diagnosis codes (up to 6), service location, facility and provider TIN/NPI, caller contact, and relevant clinical information; providing complete clinical information upfront expedites determination.

Patient name, DOB, Humana member ID
Date of service or admission
HCPCS codes and up to 6 diagnosis codes
Service location and facility/provider TIN & NPI
Caller/requester name and phone number and attending provider phone
Relevant clinical information

Step Therapy

Step therapy for Medicare Part B medications

Step therapy may apply to Medicare Part B medications; Humana maintains a Medicare Part B Step Therapy Preferred Drug List and some strategies may require trials across Part B and Part D benefits.

Review Humana's Part B Step Therapy PDL and coverage policies for specific requirements
Preferred status does not guarantee exemption from step therapy

Prior Authorization

Transplant preauthorization routing

Certain transplant-related preauthorization requests are reviewed by the Humana National Transplant Network and have separate submission contacts.

Transplant reviews are handled by the Humana National Transplant Network

Prior Authorization

Requesting prior authorization — medication entries

Use the provided fax request forms to submit preauthorization or to provide notification for medications; each medication entry lists the applicable billing code(s) to include with the request.

Medication entries include brand/generic names and billing codes (e.g., J9382, Q5152, C9399, J3490, J3590, J9999, J9039)

Prior Authorization

Transplant preauthorization submission

Preauthorization requests that require transplant review can be submitted to the Humana National Transplant Network by fax, phone, or email: fax 502-508-9300, phone 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or email transplant@humana.com.

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

Prior Authorization

How to request prior authorization / submission channels

Except where noted, prior authorization may be initiated online via CoverMyMeds, by phone at 866-461-7273 (TTY: 711), or by fax at 888-447-3430; request forms are available on Humana's prior authorization for professionally administered drugs website.

Online: CoverMyMeds
Phone: 866-461-7273 (TTY: 711)
Fax: 888-447-3430

Documentation Required

Notation key for authorization requirements

Notation keys in the list indicate: * = new preauthorization requirement; † = new-to-market drug; ‡ = shared HCPCS/NOC codes require a corresponding NDC on all claims; ** = step therapy required through a Humana-preferred drug as part of preauthorization.

* New preauthorization requirement
† New-to-market drug addition
‡ Shared HCPCS/NOC codes require corresponding NDC on claims
** Step therapy required through a Humana-preferred drug as part of preauthorization
†† Transplant-reviewed items (see transplant contacts)

Prior Authorization

Transplant review submission methods

Preauthorization requests that will be reviewed by the Humana National Transplant Network can be submitted by fax to 502-508-9300, by phone at 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or by email to transplant@humana.com.

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

Prior Authorization

How to request prior authorization / notification

Access and submit the Humana fax forms to request preauthorization or to provide notification for medications; the list provides medication names and billing codes to include in the submission.

Medication entries include brand, generic name, and billing codes for authorization

Prior Authorization

How to request prior authorization (medication list segment)

For the medications in the list segment, use the fax forms to request prior authorization or provide notification and include the specified billing codes shown next to each medication entry.

List includes medication name and billing codes (e.g., J1744, J2353, J0491, J9227, J7352, Q9998)

Prior Authorization

Transplant preauthorization submission

Preauthorization requests for transplant-reviewed items will be reviewed by the Humana National Transplant Network and can be submitted by fax to 502-508-9300, phone 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or email transplant@humana.com.

Transplant review contacts: fax 502-508-9300; phone 866-421-5663; email transplant@humana.com

Prior Authorization

How to request prior authorization

Prior authorization requests for listed medications are initiated by accessing the fax request forms on Humana's prior authorization website or via CoverMyMeds, phone (866-461-7273), or fax (888-447-3430).

CoverMyMeds, phone 866-461-7273, or fax 888-447-3430

Prior Authorization

How to request prior authorization

Access Humana's fax forms to request preauthorization or provide notification for medications listed on the prior authorization list; the forms and instructions are on Humana's prior authorization for professionally administered drugs webpage.

Use the listed billing codes with the fax forms when submitting requests

Prior Authorization

Transplant preauthorization submission instructions

Preauthorization requests for transplants are reviewed by the Humana National Transplant Network and can be submitted by fax to 502-508-9300, by phone at 866-421-5663 (Mon–Fri, 7 a.m.–7 p.m. CT), or by email to transplant@humana.com.

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

Access formsAccess the fax forms referenced in the document to request preauthorization or provide notification for listed medications.

inv-37: HCPCS/NDC billing requirement

HCPCS/NDC billing requirementShared HCPCS codes and not otherwise classified (NOC) codes require a corresponding NDC to be billed on all claims (annotated with '‡').

Examples in listItems such as Mozobil (J2562) and Neulasta/Neulasta Onpro (J2506) are shown with the '‡' notation in the medication entries.

Provider obligationInclude the corresponding NDC on the claim form when billing shared HCPCS or NOC codes to meet Humana requirements.

inv-38: Step therapy

Step therapy definitionStep therapy may apply for Medicare Part B medications; some items require trial of a Humana-preferred drug as part of preauthorization ('**').

Reference listItems requiring step therapy are annotated with '**' in the medication list sections.

Cross-benefit trialsHumana maintains a Part B Step Therapy Preferred Drug List and cross-benefit strategies may require trials across Part B and Part D.

inv-39: Annotation keys

Annotation key summary* = New preauthorization requirement; † = New-to-market drug; ‡ = NDC required for shared HCPCS/NOC codes; ** = Step therapy required; †† = Transplant review.

Where shownThese annotation keys appear alongside medication entries throughout the prior authorization list.

Use by providersUse the annotations to identify billing, step therapy, and routing requirements for each item prior to submission.

inv-40: ‡ (NDC billing requirement)

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

Document locationsThe '‡' notation is repeated in multiple medication entry sections (e.g., Monoferric, Mozobil, Neulasta entries).

Billing actionInclude corresponding NDC on claims when billing items annotated with '‡'.

inv-41: ** (step therapy)

** meaningStep therapy required through a Humana-preferred drug as part of preauthorization (items annotated with '**').

ApplicationStep therapy notation appears next to multiple products throughout the list (see medication entries).

Provider stepVerify required step-therapy trials per Humana's Part B Step Therapy Preferred Drug List when submitting authorization.

inv-42: †† (transplant review)

†† meaningPreauthorization requests for items annotated with '††' will be reviewed by the Humana National Transplant Network.

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

Where usedAnnotation '††' is used for transplant-related medications/products (e.g., Yescarta, Skysona entries).

inv-43: Preauthorization requests reviewed by the Humana National Transplant Network

Review by Humana National Transplant NetworkPreauthorization requests for transplant-reviewed items will be reviewed by the Humana National Transplant Network.

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

AnnotationSuch items are annotated with '††' in the medication list.

inv-44: Shared HCPCS and NOC codes that require a corresponding NDC on claims

Shared HCPCS/NOC require NDCShared HCPCS and not otherwise classified (NOC) codes require a corresponding NDC to be billed on all claims (annotated '‡').

Reiterated across documentThe NDC requirement is stated repeatedly in the notation/key sections and alongside specific medication entries.

Provider actionEnsure the corresponding NDC is present on claims for any shared HCPCS/NOC-coded item to meet Humana requirements.

inv-45: Step therapy required through a Humana-preferred drug as part of preauthorization

Step therapy via Humana-preferred drugSome items require step therapy through a Humana-preferred drug as part of preauthorization (annotated '**').

DocumentationStep therapy requirements are noted in the annotation key and adjacent to medication entries in the list.

Action for providersConfirm required trial of preferred agent prior to or as part of preauthorization submission.

inv-46: Shared HCPCS and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims.

NOC/HCPCS NDC requirementShared HCPCS and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on all claims (annotated '‡').

ExamplesExamples in the medication entries include products flagged with '‡' next to their billing codes (see Monoferric, Mozobil, Neulasta entries).

Billing complianceClaims for NOC/shared HCPCS-coded items must include NDCs to comply with Humana billing rules.

inv-47: Step therapy required through a Humana-preferred drug as part of preauthorization.

Step therapy requirement ('**')Step therapy is required through a Humana-preferred drug as part of preauthorization for items annotated with '**'.

Reference notesThe notation is detailed in the annotation key and repeated in medication entry sections.

Provider instructionWhen '**' is present, verify step-therapy prerequisites per Humana's Part B Step Therapy Preferred Drug List before submitting authorization.

inv-48: Preauthorization requests for these items will be reviewed by the Humana National Transplant Network (contact info provided).

Transplant review routingPreauthorization requests for items annotated with '††' will be reviewed by the Humana National Transplant Network; contact details provided.

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

ExamplesTransplant-reviewed items include entries such as Skysona and Yescarta annotated '††'.

inv-49: New preauthorization requirement (indicated in list).

New preauthorization requirement ('*')Items annotated with '*' indicate a new preauthorization requirement added to the list.

Where notedThe '*' notation is included in the annotation key and appears beside specific medication entries in the list.

Provider actionCheck entries marked '*' for newly added prior authorization requirements before providing services.

inv-50: Step therapy required through a Humana-preferred drug as part of preauthorization

Step therapy via preferred drug for some itemsSome medication entries require step therapy through a Humana-preferred drug as part of preauthorization (annotated '**').

Notation placementThe '**' annotation appears next to product names and billing codes throughout the list.

Verify prior to requestConfirm required step therapy trials and document evidence when submitting authorization.

inv-51: * / †

'* / †' meaning'*' denotes new preauthorization requirement; '†' denotes new-to-market drug addition.

Use in listBoth symbols are used in the annotation key and appear alongside specific medication entries.

Provider noteReview items annotated with '*' or '†' for updated authorization or clinical documentation needs.

inv-52: ††

'††' meaningIndicates items whose preauthorization requests will be reviewed by the Humana National Transplant Network.

Submission methodsFax to 502-508-9300; phone 866-421-5663 (Mon–Fri 7 a.m.–7 p.m. CT); email transplant@humana.com.

ExamplesTransplant-related products such as Yescarta and Skysona are annotated with '††'.