Prior Authorization
Certain drugs require prior authorization (PA) or a medical exception for coverage. If the drug requires this step, a member’s doctor will need to request and receive approval from Humana before the drug may be covered by their insurance plan.
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 which 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:
- AHFS (American Hospital Formulary Service) Compendium
- Thompson Micromedex/DrugDex (not Drug Points) Compendium
- NCCN Drugs and Biologics Compendium
- Elsevier Gold Standard's Clinical Pharmacology Compendium
Instructions for: United States | Puerto Rico
Request Submission
Doctors can submit their requests to the Humana Clinical Pharmacy Review (HCPR) through the following methods.
Phone & Fax Requests
| Hours: | 8:00 AM to 9:00 PM 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 |
General Fax Form
If a drug does not have a custom form below, please use the General Fax Form.
- General Fax Form
- (44 KB) Download PDF
- English
Non-Formulary Drug Authorization Request
- (190 KB) Download PDF
- English
Customized Fax Forms
| Aciphex - PPI (Proton Pump Inhibitor) |
|
|---|---|
| Actimmune |
|
| Actiq |
|
| Adcirca |
|
| Allegra |
|
| Afinitor |
|
| Allegra-D |
|
| Aloxi IV Injection |
|
| Amevive |
|
| Amrix |
|
| Anzemet |
|
| Apokyn |
|
| Aralast |
|
| Aranesp |
|
| Arcalyst (rilonacept) |
|
| Arixtra |
|
| Arranon |
|
| Arthrotec |
|
| Avastin |
|
| Avonex (multiple sclerosis) |
|
| Banzel |
|
| Berinert |
|
| Betaseron (multiple sclerosis) |
|
| Boniva IV |
|
| Botox |
|
| Brovana |
|
| Byetta |
|
| Cancidas |
|
| Celebrex |
|
| Cesamet |
|
| Cimzia |
|
| Cinryze |
|
| Clarinex |
|
| Clarinex-D |
|
| Clark Memorial Brand-Name Multi-source Co-payment Review Request Fax Form |
|
| Copaxone (multiple sclerosis) |
|
| Copegus |
|
| Coreg CR |
|
| Cubicin |
|
| Dacogen |
|
| Degarelix |
|
| Dysport |
|
| Elaprase |
|
| Eligard |
|
| Emend IV |
|
| Embeda |
|
| Enbrel |
|
| Epogen |
|
| Erbitux |
|
| Euflexxa |
|
| Exjade |
|
| Fareston |
|
| Fentora |
|
| Fexmid |
|
| Fexofenadine |
|
| Fibricor |
|
| Flector |
|
| Flolan |
|
| Folotyn (pralatrexate) |
|
| Forteo |
|
| Fosrenol |
|
| Fragmin |
|
| Fusilev |
|
| Genotropin (Growth Hormone) |
|
| Gleevec |
|
| Hemophilia |
|
| Humatrope (ADULT) |
|
| Humatrope (PEDIATRIC) |
|
| Humira |
|
| Herceptin |
|
| Hyalgan |
|
| Hyperpigmentation Agents - Ohio Health Only |
|
| Ilaris |
|
| Increlex |
|
| Infergen |
|
| Innohep |
|
| Intron-A |
|
| Investigational Authorization |
|
| IVIG (Intravenous Immune Globulin) |
|
| Ixempra |
|
| Januvia/Janumet |
|
| Kapidex |
|
| Kapidex |
|
| Kepivance |
|
| Keppra XR |
|
| Ketek |
|
| Kineret |
|
| Kuvan |
|
| Kytril |
|
| Lamisil |
|
| Letairis |
|
| Leukine |
|
| Lovenox |
|
| Lucentis |
|
| Lupron |
|
| Lyrica |
|
| Macugen |
|
| Medicare Part B vs. Part D |
|
| Mepron |
|
| Mozobil |
|
| Multaq |
|
| Multi-Source Brand-Name Review |
|
| Moxatag (amoxicillin extended release) |
|
| Mycamine |
|
| Myobloc |
|
| Neupogen |
|
| Neutrexin |
|
| Neulasta |
|
| Nexavar |
|
| Nexium - PPI (Proton Pump Inhibitor) |
|
| Nilandron |
|
| Non-Formulary |
|
| Norditropin (ADULT) |
|
| Norditropin (PEDIATRIC) |
|
| Noxafil |
|
| Nplate |
|
| Nutropin (ADULT) |
|
| Nutropin (PEDIATRIC) |
|
| Nuvigil |
|
| Omeprazole - PPI (Proton Pump Inhibitor) |
|
| Omnitrope (ADULT) |
|
| Omnitrope (PEDIATRIC) |
|
| Onsolis |
|
| Orencia |
|
| Onglyza |
|
| Orthovisc |
|
| Ozurdex |
|
| Pegasys |
|
| Peg-Intron |
|
| Penlac |
|
| Prialt |
|
| Provigil |
|
| Prevacid - PPI (Proton Pump Inhibitor) |
|
| Promacta |
|
| Prilosec - PPI (Proton Pump Inhibitor) |
|
| Protonix - PPI (Proton Pump Inhibitor) |
|
| Prolastin |
|
| Procrit |
|
| Rebetol |
|
| Rebetron |
|
| Roferon A |
|
| Rebif (multiple sclerosis) |
|
| Remicade |
|
| Revlimid |
|
| Remodulin |
|
| Revatio |
|
| Reclast |
|
| Relistor |
|
| RibaPak |
|
| Ribasphere |
|
| Ribavirin |
|
| RibTab |
|
| Rituxan |
|
| Saizen (Growth Hormone) |
|
| Sancuso |
|
| Sandostatin |
|
| Sandostatin LAR |
|
| Saphris |
|
| Savella |
|
| Selzentry |
|
| Sensipar |
|
| Serostim (ADULT) |
|
| Serostim (PEDIATRIC) |
|
| Simcor |
|
| Simponi |
|
| Smoking Cessation (Commercial Only) |
|
| Soliris |
|
| Somatuline |
|
| Somavert |
|
| Soriatane |
|
| Sporanox |
|
| Sprycel |
|
| Supartz |
|
| Sutent |
|
| Synvisc |
|
| Symlin |
|
| Synagis Order Form |
|
| Tarceva |
|
| Targretin |
|
| Tasmar |
|
| Tekturna |
|
| Tev-Tropin (ADULT) |
|
| Tev-Tropin (PEDIATRIC) |
|
| Thalomid |
|
| Tobi |
|
| Tysabri |
|
| Trilipix |
|
| Tasigna |
|
| Torisel |
|
| Treanda |
|
| Tykerb |
|
| Tracleer |
|
| Trelstar |
|
| Uloric |
|
| Universal Fax Form |
|
| Valturna |
|
| Valcyte |
|
| Vantas |
|
| Velcade |
|
| Ventavis |
|
| Vectibix |
|
| Virazole |
|
| Viadur |
|
| Visudyne |
|
| Vidaza Injection |
|
| Vivitrol |
|
| Xifaxan |
|
| Xolair |
|
| Xyzal |
|
| Xenazine |
|
| Zetia |
|
| Zolinza |
|
| Zometa |
|
| Zyvox |
|
| Zegerid - PPI (Proton Pump Inhibitor) |
|
| Zemaria |
|
| Zipsor (diclofenac potassium) |
|
| Zofran |
|
| Zorbtive (ADULT) |
|
| Zorbtive (PEDIATRIC) |
|
| Zoladex |
|
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
