Humana Prior Auth & Notification Policy Update | OpenPayer
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Prior authorization and notification list — Humana Dual Fully Integrated (HMO D-SNP) Virginia
Governs prior authorization and notification requirements for medications and administered services for Humana Dual Fully Integrated (HMO D-SNP) plans in Virginia, and informs providers how to request authorizations and required information.
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 clinical changes)
Effective Date07/01/2026
Next Review DateN/A
Key ActionInitiate medication prior authorization online via CoverMyMeds, by phone at 866-461-7273 (TTY: 711) or by fax to 888-447-3430; transplant-related requests use Humana National Transplant Network contacts.
No material clinical or coverage changes in this revision.
90 daysNo prior auth required for active treatment (new members)
866-461-7273Phone to initiate prior auth/ACD
888-447-3430Fax to submit prior auth
866-421-5663Transplant review contact (phone)
502-508-9300
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Transplant review contact (fax)
20+Medications listed (excerpt)
Prior Authorization and Coverage Criteria
Prior authorization information and criteria nodes
Coverage and prior authorization requirements adhere to Medicare coverage guidelines and Humana's coverage policies; prior authorization requests should include member and service details and relevant clinical information.
Include patient name, date of birth and Humana member ID number
Provide date of actual service or hospital admission
Provide Healthcare Common Procedure Coding System (HCPCS) code(s) and diagnosis codes (up to a maximum of 6 per authorization request)
Specify service location (inpatient or outpatient and specific site such as office, home, ambulatory surgery center, on-campus/off-campus outpatient hospital)
Include Tax Identification Number (TIN) and National Provider Identifier (NPI) for facility where service is rendered and for the provider performing the service
Provide caller/requester name and phone number and attending provider's phone number
Submit relevant clinical information to support medical necessity (provide complete clinical documentation at time of request to expedite determination)
Services must follow Medicare coverage guidelines and be medically necessary; consult CMS and Humana Medical and Pharmacy Coverage Policies
Step therapy note: Some medications require step therapy; review Humana's Medicare Part B Step Therapy Preferred Drug List for preferred agents and cross-benefit strategies
Prior authorization submission rules and notes (partial)
Provider submission requirements and special notes for certain products
Access the fax forms referenced in the list to request prior authorization or provide notification for each listed medication
For products marked with †† (transplant-related), preauthorization requests will be reviewed by the Humana National Transplant Network (fax 502-508-9300; phone 866-421-5663; email transplant@humana.com)
All shared HCPCS codes and not otherwise classified codes (marked with †) require a corresponding NDC to be billed on all claims
Step therapy (marked with **) is required through a Humana-preferred drug as part of preauthorization for drugs so indicated
Provider note: This excerpt lists brand and generic names with billing codes; consult the full prior authorization and notification list and Humana coverage policies for any additional clinical criteria
coverage_requirements_listed_drugs
Medications listed require prior authorization or notification for Humana Dual Fully Integrated (HMO D-SNP) Virginia; providers should access fax forms to submit requests and follow special instructions where noted.
Prior authorization or notification is required for the medications listed for Humana Dual Fully Integrated (HMO D-SNP) Virginia members; each entry includes brand name, generic name and billing code(s)
Follow the submission instructions (access fax forms) associated with each medication entry
Symbols and flags: Entries may include flags: * = new preauthorization requirement; † = new-to-market drug; ‡ = shared HCPCS/NOC codes require corresponding NDC; ** = step therapy required; †† = transplant review
Medications listed require prior authorization or notification for Humana Dual Fully Integrated (HMO D-SNP) Virginia members. Each entry includes brand name, generic name, and billing code(s). Special symbols denote billing/NDC requirements, step therapy, new-to-market status, and transplant review instructions.
Each listed medication entry provides brand name, generic medication name and associated billing code(s) (HCPCS/J/Q/C codes)
When an entry is marked with the HCPCS/NOC indicator (‡), include the corresponding NDC on the claim when billing shared HCPCS or NOC codes
For entries marked with **, step therapy through a Humana-preferred drug is required as part of the preauthorization process
For entries marked with ††, submit preauthorization requests to the Humana National Transplant Network for review (fax/phone/email contacts provided in the list)
Provider action:
Prior Authorization Requirements and Process
Medications listed require prior authorization/notification as indicated; billing codes provided for claim submission and notes on coding and step therapy apply.
Prior authorization or notification is required for the drugs listed when billed for Humana Dual Fully Integrated (HMO D-SNP) Virginia members
Shared HCPCS and NOC codes marked with the HCPCS/NOC flag (‡) must include a corresponding NDC on all claims
Step therapy (marked **) is required through a Humana-preferred drug as part of preauthorization for specified agents
Transplant-related preauthorization requests (marked ††) are routed to the Humana National Transplant Network and can be submitted by fax (502-508-9300), phone (866-421-5663, Mon-Fri 7a-7p CT) or email (transplant@humana.com)
Providers should access the fax forms referenced in the list to request prior authorization or provide notification for each drug; include required member, provider, coding and clinical information to expedite review
Billing Codes and Code Lists
Examples of listed medications with billing codesHCPCS
J9264
Abraxane
J3262
Actemra IV
Q2055
Abecma
J0172
Aduhelm
Examples of listed medications with billing codes - supporting entriesHCPCS
Q2055
Abecma (idecabtagene vicleucel)
J9264
Abraxane (paclitaxel-nab)
Examples of listed medications with billing codes - additionalHCPCS
Not otherwise classified drugs — used for several listed products
J3490
Unclassified drugs (J3490) — used for several listed products
J3590
Unclassified drugs (J3590) — used for several listed products
various J- and Q- codes
Specific HCPCS/CPT/J/Q codes listed per medication entry throughout document
examples from listHCPCS
J1304
Qalsody
C9399
Various NOC billing for specified drugs (example: Qivigy/Rybrevant Faspro)
J1301
Radicava
J1745
Remicade (infliximab)
J9021
Rylaze (asparaginase erwinia chrysanthemi)
J2326
Spinraza (nusinersen)
J3241
Tepezza (teprotumumab-trbw)
J2356
Tezspire (tezepelumab-ekko)
J1303
Ultomiris (ravulizumab-cwvz)
J2327
Skyrizi IV (risankizumab-rzaa)
1–10 of 11
1/2
Example HCPCS/NOC codes from listHCPCS
C9399
Not otherwise classified HCPCS (example listed for Unituxin)
J3490
Unclassified drugs
Additional HCPCS/Q-codesHCPCS
J9303
Vectibix
Q5129
Vegzelma
Blood-clotting factor codes (sample)HCPCS
J7192
Advate / antihemophilic factor
J7207
Adynovate
How to Request Prior Authorization and Provider Requirements
Prior Authorization
Medication-specific prior authorization/notification list (selected entries)
The list below shows selected medications that require prior authorization or notification for Humana Dual Fully Integrated (HMO D-SNP) Virginia plans. For each entry, the brand name is listed first followed by the generic name (when provided) and associated billing codes. Access Humana's fax forms to request prior authorization or provide notification. Notes: * = New preauthorization requirement; † = New-to-market drug addition; ‡ = All shared HCPCS and NOC codes require a corresponding NDC on claims; ** = Step therapy required through a Humana-preferred drug as part of preauthorization; †† = Preauthorization requests reviewed by Humana National Transplant Network (fax 502-508-9300, phone 866-421-5663, Mon–Fri 7 a.m.–7 p.m. CT, email transplant@humana.com).
DefinitionPrior authorization is a process requiring the healthcare provider to obtain advance approval from the plan to determine whether an item or service will be covered.
ScopeApplies to medications administered in provider settings (office, clinic, outpatient, home) for Humana Dual Fully Integrated (HMO D-SNP) Virginia.
Required request contentInclude member identifiers (name, DOB, Humana member ID), provider identifiers, HCPCS/J-code(s) and diagnosis codes (up to 6), service location, and supporting clinical information.
Regulatory referenceServices must follow Medicare coverage guidelines; consult CMS and Humana Medical and Pharmacy Coverage Policies for criteria.
Consequences of no PAServices provided without prior authorization may be subject to retrospective medical necessity review and potential financial penalties or reduced benefits.
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 clinical changes)
Effective Date07/01/2026
Next Review DateN/A
Key ActionInitiate medication prior authorization online via CoverMyMeds, by phone at 866-461-7273 (TTY: 711) or by fax to 888-447-3430; transplant-related requests use Humana National Transplant Network contacts.
Use the fax forms referenced for each drug to submit prior authorization or notification; see full list for clinical details and any supplemental criteria
Vyxeos, Wainua, and others listed above follow the same prior authorization/notification process described; consult Humana provider resources for full forms and instructions.
inv-25: step therapy
DefinitionStep therapy requires trial of a Humana-preferred drug before approving a non-preferred agent.
Reference PDLSee Humana's Medicare Part B Step Therapy Preferred Drug List (PDL) for preferred/nonpreferred medications and cross-benefit strategies.
Cross-benefit trialsSome strategies may require trials across Medicare Part B and Part D; consult the Part B Step Therapy PDL for details.
Program effectPreferred designation does not guarantee exemption from step therapy; specific coverage criteria apply.
inv-26: List notation
Notation element 11 = Generic medication name.
Notation element 22 = Billing codes associated with the medication.
UsageEach list entry shows Brand name, 1 (generic name), and 2 (billing codes) to standardize interpretation of the medication list.
inv-27: Notation key
‡ symbolIndicates all shared HCPCS and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) on all claims.
** symbolIndicates step therapy is required through a Humana-preferred drug as part of preauthorization.
* and † symbols* marks new preauthorization requirement; † marks new-to-market drug addition.
†† symbolIndicates preauthorization requests will be reviewed by the Humana National Transplant Network and provides submission contacts.
inv-28: Transplant preauthorization review
Review pathwayTransplant-related preauthorization requests are reviewed by the Humana National Transplant Network.
FormsAccess the referenced fax forms in the medication list to request transplant-related preauthorization or provide notification.
inv-29: footnotes/flags
* (asterisk)New preauthorization requirement.
† (dagger)New-to-market drug addition.
‡ (double-dagger)Shared HCPCS/NOC codes require corresponding NDC on claims.
** (double asterisk)Step therapy required through a Humana-preferred drug as part of preauthorization.
†† (double dagger/different)Marks items routed to Humana National Transplant Network for review.
inv-30: symbols used
††Transplant review — submit via fax 502-508-9300, phone 866-421-5663, Mon-Fri 7a-7p CT, or email transplant@humana.com.
‡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.
inv-31: Humana prior authorization list (VA HMO D-SNP)
Plan and populationHumana Dual Fully Integrated (HMO D-SNP) Virginia prior authorization and notification list covers medications administered in provider settings for plan members.
PurposeSpecifies which medications require prior authorization or notification and how to submit requests (fax forms, phone, online options).
Billing guidanceShared HCPCS and NOC codes (e.g., C9399, J3490) require corresponding NDCs on claims; specific HCPCS/J/Q codes listed per medication.
Effective date07/01/2026.
inv-32: document symbols and notes
‡All shared HCPCS and NOC codes require a corresponding NDC on all claims.
**Step therapy required through a Humana-preferred drug as part of preauthorization.
* and †* = new preauthorization requirement; † = new-to-market drug addition.
††Transplant preauthorization reviewed by Humana National Transplant Network; contact/fax/phone/email provided in list.