Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
List of medications commonly reviewed by Humana Healthy Horizons in Virginia that may require prior authorization or notification when administered in provider offices, clinics, outpatient or home settings; applies to providers submitting claims for Virginia Medicaid members.
No material clinical or coverage changes in this revision.
Coverage Criteria
General prior authorization requirement
Covered when prior authorization or notification requirements are met as specified by Humana Healthy Horizons in Virginia
Urgent/emergent services do not require prior authorization.
Initial Authorization (list-based)
Drugs listed require prior authorization; specific medical necessity criteria are not included in these chunks.
See transplant review process for †† items; include corresponding NDC for shared HCPCS/NOC codes.
General prior authorization criteria
Covered when prior authorization is obtained for the listed professionally administered medications and appropriate billing requirements are met
Applies to drugs listed in the professionally administered medication prior authorization list; failure to obtain prior authorization may result in financial penalties or retrospective review.
Prior authorization is required for professionally administered medications listed in this document unless otherwise noted. Urgent/emergent services do not require prior authorization. Providers should verify whether a given drug on the list requires prior authorization or notification before administration to avoid potential claim denials or retrospective reviews.
No additional exclusions are explicitly listed in the provided excerpts beyond the general statement that shared HCPCS and not otherwise classified (NOC) codes require a corresponding National Drug Code for claim submission and the notation conventions for new-to-market and transplant-reviewed items. Providers should follow the code-specific instructions and legend when billing.
Investigational and experimental procedures generally are not covered benefits under Humana Healthy Horizons in Virginia. Providers should contact Humana Healthy Horizons to confirm coverage status for any investigational or experimental service before delivery.
This section has no additional content in the provided excerpts.
Coding and Billing Codes
| Q2055 | Abecma (idecabtagene vicleucel) — listed |
| J9264 | Abraxane (paclitaxel-nab) — listed |
| J3262 | Actemra IV (tocilizumab) — listed |
| J0791 | Adakveo (crizanlizumab-tmca) — listed |
| J9042 | Adcetris (brentuximab vedotin) — listed |
| J9029 | Adstiladrin (nadofaragene firadenovec-vncg) — listed |
| J7171 | Adzynma (ADAMTS13, recombinant-krhn) — listed |
| J1744 | icatibant |
| J7355 | travoprost intracameral implant (iDose TR 75mcg intracameral implant) |
| J0638 | canakinumab (Ilaris) |
| J3245 | tildrakizumab-asmn (Ilumya) |
| J7313 | fluocinolone acetonide (Iluvien) |
| J9256 | nipocalimab-aahu (Imaavy) |
| J9026 | tarlatamab-dlle (Imdelltra) |
| J9173 | durvalumab (Imfinzi) |
| J9347 | tremelimumab-actl (Imjudo) |
| J9325 | talimogene laherparepvec (Imlygic) |
| J3490 | not otherwise classified (used with multiple entries) |
| J3590 | not otherwise classified (alternate) |
| J9043 | cabazitaxel (Jevtana) |
| Q5160 | bevacizumab-nwgd (Jobevne) |
| Q5136 | denosumab-bbdz (Jubbonti) |
| J9354 | ado-trastuzumab emtansine (Kadcyla) |
| J1290 | ecallantide (Kalbitor) |
| Q5117 | trastuzumab-anns (Kanjinti) |
| J2840 | sebelipase alfa (Kanuma) |
| C9399 | not otherwise classified chemotherapy/drug (used with multiple gene/cellular therapies) |
| J0887 | methoxy polyethylene glycol - epoetin beta (Mircera ESRD) |
| J0888 | methoxy polyethylene glycol - epoetin beta (Mircera non-ESRD) |
| J0217 | velmanase alfa-tycv (Lamzede) |
| J1932 | lanreotide (Cipla) |
| J1930 | lanreotide (listed with ‡ as shared HCPCS) |
| J3398 | voretigene neparvovec-rzyl (Luxturna) |
| J2820 | sargramostim (Leukine) |
| J0013 | Spravato / esketamine (as listed) |
| S0013 | Spravato (alternate code) |
| G2082 | Spravato (alternate code) |
| G2083 | Spravato (alternate code) |
| C9399 | Starjemza IV / unclassified code (requires NDC) |
| J3490 | Starjemza IV / J-code (not otherwise classified) |
| J3590 | Starjemza IV / J-code (not otherwise classified) |
| J3358 | Stelara IV / ustekinumab |
| J3357 | Stelara SQ / ustekinumab |
| Q5099 | Steqeyma IV / ustekinumab-stba |
| J9022 | Tecentriq / atezolizumab |
| J9024 | Tecentriq Hybreza / atezolizumab and hyaluronidase-tqjs |
| C9399 | Tegsedi / inotersen (unclassified; requires NDC) |
| J3490 | Tegsedi / inotersen (not otherwise classified) |
| J3241 | Tepezza / teprotumumab-trbw |
| J1073 | Testopel (75mg) / testosterone pellet |
| J9329 | Tevimbra / tislelizumab-jsgr |
| J2356 | Tezspire / tezepelumab-ekko |
| J7197 | Thrombate III / antithrombin III |
| Q5133 | Tofidence IV / tocilizumab-bavi |
Provider Actions and Submission Instructions
Prior authorization and notification requirements
Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list Effective date: 01/01/2026 Revision date: 05/20/2026 The following list describes medications that are commonly reviewed and may require additional clinical information. Medications include those that are delivered in the provider's office, a clinic, or an outpatient or home setting. Please note the term prior authorization (also known as preauthorization, precertification or preadmission), when used in this communication, is defined as a process through which the healthcare provider is required to obtain advance approval from Humana Healthy Horizons® in Virginia as to whether an item or service will be covered. Notification refers to the process by which the healthcare provider notifies Humana Healthy Horizons of the intent to provide an item or service. Humana Healthy Horizons requests notification as it helps coordinate care for members. This process is distinguished from prior authorization. Humana Healthy Horizons does not issue approvals or denials for notifications. Investigational and experimental procedures usually are not covered benefits. Please contact Humana Healthy Horizons for confirmation of coverage. Please note: Urgent/emergent services do not require prior authorization. Failure to obtain prior authorization for a medication could result in financial penalties for the provider and reduced benefits for the member. Services or medications provided without prior authorization may be subject to retrospective medical necessity review. Humana Healthy Horizons recommends individual providers making specific requests for services or medications verify benefits and prior authorization requirements with Humana Healthy Horizons prior to providing services.
How to request prior authorization
Humana Healthy Horizons handles all prior authorization requests for medications typically received as an injection at a healthcare provider's office. You can initiate prior authorization by:
- Submit your request online at the CoverMyMeds® website.
- Fax requests to 888-447-3430. Request forms can be found by visiting Humana's prior authorization for professionally administered drugs webpage.
- Call 866-461-7273, Monday - Friday, 8 a.m. - 11 p.m., Eastern time.
Prior authorization required for listed drugs
Prior authorization is required for all drugs listed in the Humana Healthy Horizons in Virginia professionally administered medication prior authorization list. The list is subject to change; additions may include new-to-market medications or step-therapy requirements. Urgent/emergent services do not require prior authorization.
Transplant preauthorization routing
Preauthorization requests for items marked with †† (transplant-related) will be reviewed by the Humana National Transplant Network. These requests may be submitted by fax, phone, or email for specialized review and coordination.
- Fax for transplant review: 502-508-9300.
- Phone for transplant review: 866-421-5663, Monday – Friday, 7 a.m. – 7 p.m., Central time.
- Email for transplant review: transplant@humana.com
Missing NDC for shared HCPCS/NOC
All shared HCPCS codes and not otherwise classified (NOC) codes require a corresponding National Drug Code (NDC) to be billed on claims. Failure to include the corresponding NDC on claims for shared HCPCS or NOC codes may result in claim denials or billing noncompliance.
Use fax forms for prior authorization
Please access and use the Humana fax forms to request prior authorization or provide notification when indicated. Using the correct forms and including required documentation (clinical rationale, dosing, member identifiers, and NDC where applicable) helps avoid processing delays.
- Locate fax forms on Humana's prior authorization for professionally administered drugs webpage.
- Include clinical documentation and the corresponding NDC for shared HCPCS/NOC codes.
Failure to obtain prior authorization
Failure to obtain required prior authorization may result in financial penalties to the provider and reduced member benefits. Services provided without prior authorization may be subject to retrospective medical necessity review.
Step-therapy notice
This prior authorization list may be modified throughout the year to add new-to-market medications or implement step-therapy requirements. Providers should verify the current list and any step-therapy edits before administering medications.
Initial Therapy Criteria
Initial Therapy (list)
Prior authorization required for initial administration of listed professionally administered medications.
Contact transplant@humana.com or fax/phone as provided for †† items.
Step Therapy
| Step | Notice |
|---|---|
| 1 | List may be modified throughout the year for additions of new-to-market medications or step-therapy requirements; specific step-therapy rules are not detailed in this document. |
Site of Care
Site of care: office/clinic/home
Medications in this list are those delivered in the provider's office, a clinic, or an outpatient or home setting; ensure prior authorization is obtained when required before administration in these settings.
Billing: use professional/infusion administration codes
Professionally administered medications are typically billed under professional/infusion administration codes; use the listed HCPCS/J/Q/C codes for claims and follow site-of-care billing rules.
Infusion center billing and transplant review
Medications administered in infusion centers must be billed using the listed HCPCS/J/Q/C codes and, where noted (‡), include a corresponding NDC; transplant products (††) require National Transplant Network review.
Background
This document is an administrative list of professionally administered medications that may require prior authorization or notification when provided in a provider office, clinic, outpatient facility, or home setting. It defines prior authorization as the process by which a provider obtains advance approval from Humana Healthy Horizons in Virginia to determine whether an item or service will be covered, and distinguishes notification as the provider informing Humana of the intent to provide a service (Humana does not issue approvals or denials for notifications). The list highlights billing considerations and notes that failure to obtain required prior authorization may result in financial penalties for the provider and reduced benefits for the member.
Definitions and Symbols
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