Prior Authorization Required

Prior authorization (PA) is required for the medications listed on this Prior Authorization and Notification List (PAL). Providers must submit PA requests for provider-administered medications using one of the available channels. Requests may be submitted online via CoverMyMeds, by phone, or by fax (forms available on Humana's prior authorization for professionally administered drugs page). Billing codes (HCPCS/J-/Q-/C-codes or C9399/J3490/J3590 when noted) are provided next to each product in the list and must be used when submitting requests. Failure to obtain required PA may result in financial liability for the provider and reduced member benefits.

• Online: CoverMyMeds (https://www.covermymeds.health/)
• Phone: 866-461-7273 (TTY: 711), Monday - Friday, 8 a.m. - 11 p.m. ET
• Fax: 888-447-3430 (request forms available on Humana's prior authorization for professionally administered drugs website)

Urgent/Emergent Services

Urgent or emergent services do not require referrals or prior authorizations. However, services provided without prior authorization when one is normally required may be subject to retrospective medical necessity review and potential financial penalties under the provider contract or the member’s Evidence of Coverage.

Step Therapy Guidance

Step therapy may apply for certain Medicare Part B medications. Humana's Medicare Part B Step Therapy Preferred Drug List (PDL) — including preferred and nonpreferred medications and cross‑benefit strategies between Part B and Part D — is available on Humana's provider prior authorization notification lists website. Preferred status does not guarantee exemption from step therapy; review specific coverage criteria and the Part B Step Therapy PDL when processing requests.

• Affected medications are noted with a step therapy indicator on the Medicare PAL
• If the provider does not stock a preferred medication, it may be obtained from a pharmacy (see Humana mail-order and specialty pharmacy listings)
• For questions: 800-457-4708 (TTY: 711), daily, 8 a.m. - 8 p.m. ET

Transplant Review Process

Certain preauthorization requests will be reviewed by the Humana National Transplant Network. Transplant-related products and services identified on the PAL carry the transplant review flag (††). These requests follow a special submission and review pathway distinct from routine PA processing.

• Transplant review flag: †† — requests routed to Humana National Transplant Network
• Transplant review may apply to new-to-market or transplant-related medications/services listed on the PAL

How to Request Prior Authorization (fax forms)

Access and complete the Humana fax forms to request prior authorization or to provide notification for listed medications. Use the billing codes shown next to each product when submitting the request. Where a product is billed under a shared HCPCS or NOC code, include the corresponding NDC on claims as required.

• Complete the appropriate Humana PA/notification fax form (available on Humana's prior authorization for professionally administered drugs website)
• Include the billing code(s) listed for each product (HCPCS/J-/Q-/C-codes). When 'C9399, J3490, J3590' or similar NOC codes are listed, include the product NDC on the claim.
• If step therapy applies, document prior trials of preferred therapies per coverage criteria

General Prior Authorization Request Instruction

General instructions for prior authorization requests: except where noted, PA for medications may be initiated via CoverMyMeds, phone, or fax. The PAL is updated periodically; providers should verify current requirements on Humana's provider website. For medications requiring special handling (e.g., transplant-related, new-to-market), the PAL notes the alternate submission route or reviewer.

• Online: CoverMyMeds — use for standard PA submissions when supported
• Phone: 866-461-7273 (TTY: 711), Mon–Fri, 8 a.m. – 11 p.m. ET
• Fax: 888-447-3430 — use the Humana PA/notification fax form for the specific medication

Legend and Special Requirements

Legend and special requirements used throughout the PAL: symbols adjacent to product names indicate special handling or requirements. Providers must observe these markers and the corresponding instructions when submitting PA requests.

• * = New preauthorization requirement
• † = New-to-market drug addition
• ‡ = All shared HCPCS codes 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 will be reviewed by the Humana National Transplant Network (see Transplant Review Process)

Medication-specific Prior Authorization Instructions

Medication‑specific prior authorization instructions are provided next to each listed product in the PAL. Each entry includes the product name, generic name (when applicable), the instruction to access Humana fax forms for PA/notification, and the billing code(s) to use on the PA request and claims. For shared/NOC billing scenarios, include the NDC on the claim and use C9399/J3490/J3590 (or the listed NOC) when instructed.

• Examples of billing codes listed in the PAL: J1554, J0597, Q5152, J9039, Q5130, J9394, J9331, Q5130, J1460, J1560, J1289, J9355, J9356, Q5146, Q5113, J1559, Q5111, Q5138, J1304, J0218, J0588, J0897, J3299, J0218, J7209, J7188, J7194, J7174, J7203, J7192, J7200, J1412

Prior Authorization Notes and Special Flags

Prior authorization notes and special flags to observe when submitting requests: shared HCPCS/NOC codes require the product NDC on claims; some products are designated new preauthorization requirements or new-to-market and may have modified processes; step therapy indicators denote required trials of preferred therapies; transplant-related items require routing to the Humana National Transplant Network.

• When a shared HCPCS or NOC code (e.g., C9399, J3490, J3590) is listed, include the specific product NDC on the claim.
• Products marked with * or † may represent new PA requirements or new-to-market drugs—verify current criteria on Humana's provider website.
• Products marked with ** require step therapy per Humana's Part B PDL.

Transplant Review Contact for Preauthorization

Transplant-related preauthorization submissions and contact information: preauthorization requests flagged for transplant review (††) will be reviewed by the Humana National Transplant Network. Providers should use the dedicated submission routes to ensure timely review.

• Fax: 502-508-9300
• Phone: 866-421-5663, Monday – Friday, 7 a.m. – 7 p.m., Central time
• Email: transplant@humana.com