Prior Authorization

Please note the following regarding Medically Accepted Indications

All reasonable efforts have been made to ensure consideration of medically accepted indications in this policy. Medically accepted indications are defined by CMS as those uses of a covered Part D drug that are approved under the federal Food, Drug, and Cosmetic Act, or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in section 1927(g)(1)(B)(i) of the Act. These compendia guide review of off-label and off-evidence prescribing and are subject to minimum evidence standards for each compendium. Currently, this review includes the following references when applicable and may be subject to change per CMS:

• American Hospital Formulary Service (AHFS) Compendium
• Thomson Micromedex/DrugDex (not Drug Points) Compendium
• National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium^™
• Elsevier Gold Standard's Clinical Pharmacology Compendium

Request Submission

Doctors can submit their requests to Humana Clinical Pharmacy Review (HCPR) through the following methods.

Phone & Fax Requests

Hours: 8:00 a.m. to 9:00 p.m. EST Monday through Friday
Phone Requests: 1-800-555-CLIN (2546)
Fax Requests: Complete the applicable form below and fax to 1-877-486-2621

Fax Forms

Coverage Determination Forms

Request for Coverage Determination

(0.5 MB) Download PDF

English | Spanish

If you prefer, you may complete the form online. Before completing the form, you may want to view our accepted file types.

Coverage Determination Request Form

Another option is to use the Coverage Determination Request Form on the CMS website.

Customized Fax Forms

Universal Fax Forms

Universal

(110 KB) Download PDF

English