A Humana healthcare provider writing a prescription.

Prior Authorization

Certain drugs require prior authorization or a medical exception for coverage. For these medications, the prescriber will need to request and receive approval from Humana before the drug may be covered by the member's health plan.

Submitting a Request for Prior Authorization

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

Phone requests: 1-800-555-CLIN (2546)
Hours: 8 a.m. to 6 p.m., local time, Monday through Friday

Fax requests: Complete the applicable form below and fax to 1-877-486-2621.

Before submitting a prior authorization request for an elderly patient, please review this list of medications to avoid in the elderly. It is adapted from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) measure, Use of High-Risk Medications in the Elderly.

Fax Forms

Brand-Name Multisource Authorization (MSB)
(0.5 MB) Download PDF
Use this fax form to request use of brand-name medications that have a generic equivalent available.
English
Nonformulary Drug Authorization
(190 KB) Download PDF
Use this fax form to request use of medications not on the member's formulary.
English
High Risk Medications
(206 KB) Download PDF
Use this fax form to request use of medications identified by the Beer's criteria as potentially high risk and inappropriate for use in the elderly.
English
Louisiana Authorization Form
(175.96 KB) Download PDF
This fax form is for medication requests for a member/resident of Louisiana in accordance with LA SB 231.
English

Coverage Determination Forms

Request for Coverage Determination
(0.5 MB) Download PDF
English | Spanish

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

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

Customized Fax Forms

Byetta
(400 KB) Download PDF
English
Calcitriol
(149 KB) Download PDF
English
Diabetic Test Strips
(400 KB) Download PDF
English
Enbrel
(400 KB) Download PDF
English
Exjade
(400 KB) Download PDF
English
Flector
(400 KB) Download PDF
English
Hectorol
(149 KB) Download PDF
English

 

Humira
(400 KB) Download PDF
English
Janumet
(400 KB) Download PDF
English
Janumet XR
(209 KB) Download PDF
English
Januvia
(400 KB) Download PDF
English
Juvisync
(114 KB) Download PDF
English
Letairis
(400 KB) Download PDF
English
Lidoderm
(400 KB) Download PDF
English
Revatio
(400 KB) Download PDF
English
Revlimid
(400 KB) Download PDF
English
Tarceva
(400 KB) Download PDF
English
Tracleer
(400 KB) Download PDF
English
Victoza
(144 KB) Download PDF
English
Xifaxan
(400 KB) Download PDF
English
Zemplar
(149 KB) Download PDF
English

Universal Fax Forms

If a specific fax form for the medication being requested is not located above, please use the universal fax form

Universal
(110 KB) Download PDF
English

Note: These documents are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to Download Adobe Reader

Get Adobe Reader

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 the Centers for Medicare & Medicaid Services (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