Humana - Guidance when you need it most

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 a.m. – 9:00 p.m. EST, Monday-Friday.
Phone Requests: 1-800-555-CLIN (2546)
Fax Requests: Complete the forms 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) Healthcare PDF Download PDF
English
 
Actimmune Healthcare PDF Download PDF
English
 
Actiq Healthcare PDF Download PDF
English
 
Allegra Healthcare PDF Download PDF
English
 
Afinitor Healthcare PDF Download PDF
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Allegra-D Healthcare PDF Download PDF
English
 
Aloxi IV Injection Healthcare PDF Download PDF
English
 
Amevive/Raptiva Healthcare PDF Download PDF
English
 
Amrix Healthcare PDF Download PDF
English
 
Apokyn Healthcare PDF Download PDF
English
 
Aralast Healthcare PDF Download PDF
English
 
Aranesp Healthcare PDF Download PDF
English
 
Arranon Healthcare PDF Download PDF
English
 
Arthrotec Healthcare PDF Download PDF
English
 
Avastin Healthcare PDF Download PDF
English
 
Avonex (multiple sclerosis) Healthcare PDF Download PDF
English
 
Banzel Healthcare PDF Download PDF
English
 
Betaseron (multiple sclerosis) Healthcare PDF Download PDF
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Boniva IV Healthcare PDF Download PDF
English
 
Botox Healthcare PDF Download PDF
English
 
Brovana Healthcare PDF Download PDF
English
 
Byetta Healthcare PDF Download PDF
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Cancidas Healthcare PDF Download PDF
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Celebrex Healthcare PDF Download PDF
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Cesamet Healthcare PDF Download PDF
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Cimzia Healthcare PDF Download PDF
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Cinryze Healthcare PDF Download PDF
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Clarinex Healthcare PDF Download PDF
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Clarinex-D Healthcare PDF Download PDF
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Copaxone (multiple sclerosis) Healthcare PDF Download PDF
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Copegus Healthcare PDF Download PDF
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Coreg CR Healthcare PDF Download PDF
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Cubicin Healthcare PDF Download PDF
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Dacogen Healthcare PDF Download PDF
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Elaprase Healthcare PDF Download PDF
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Eligard Healthcare PDF Download PDF
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Ellence Healthcare PDF Download PDF
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Emend IV Healthcare PDF Download PDF
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Enbrel Healthcare PDF Download PDF
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Epogen Healthcare PDF Download PDF
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Erbitux Healthcare PDF Download PDF
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Eraxis Healthcare PDF Download PDF
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Euflexxa Healthcare PDF Download PDF
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Exjade Healthcare PDF Download PDF
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Fareston Healthcare PDF Download PDF
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Fentora Healthcare PDF Download PDF
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Fexofenadine Healthcare PDF Download PDF
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Flector Healthcare PDF Download PDF
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Flolan Healthcare PDF Download PDF
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Forteo Healthcare PDF Download PDF
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Fosrenol Healthcare PDF Download PDF
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Fusilev Healthcare PDF Download PDF
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Genotropin (Growth Hormone) Healthcare PDF Download PDF
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Gleevec Healthcare PDF Download PDF
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Hemophilia Healthcare PDF Download PDF
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Humatrope (Growth Hormone) Healthcare PDF Download PDF
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Humira Healthcare PDF Download PDF
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Herceptin Healthcare PDF Download PDF
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Hyalgan Healthcare PDF Download PDF
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Increlex Healthcare PDF Download PDF
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Infergen Healthcare PDF Download PDF
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Intron-A Healthcare PDF Download PDF
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Investigational Authorization Healthcare PDF Download PDF
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IVIG (Intravenous Immune Globulin) Healthcare PDF Download PDF
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Ixempra Healthcare PDF Download PDF
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Januvia/Janumet Healthcare PDF Download PDF
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Kapidex Healthcare PDF Download PDF
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Kepivance Healthcare PDF Download PDF
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Keppra XR Healthcare PDF Download PDF
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Ketek Healthcare PDF Download PDF
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Kineret Healthcare PDF Download PDF
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Kuvan Healthcare PDF Download PDF
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Lamisil Healthcare PDF Download PDF
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Letairis Healthcare PDF Download PDF
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Leukine Healthcare PDF Download PDF
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Lucentis Healthcare PDF Download PDF
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Lupron Healthcare PDF Download PDF
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Lyrica Healthcare PDF Download PDF
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Macugen Healthcare PDF Download PDF
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Medicare Part B vs. Part D Healthcare PDF Download PDF
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Mepron Healthcare PDF Download PDF
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Mozobil Healthcare PDF Download PDF
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Multi-Source Brand-Name Review Healthcare PDF Download PDF
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Moxatag (amoxicillin extended release) Healthcare PDF Download PDF
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Mycamine Healthcare PDF Download PDF
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Myobloc Healthcare PDF Download PDF
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Neupogen Healthcare PDF Download PDF
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Neutrexin Healthcare PDF Download PDF
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Neulasta Healthcare PDF Download PDF
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Nexavar Healthcare PDF Download PDF
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Nonformulary Healthcare PDF Download PDF
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Noxafil Healthcare PDF Download PDF
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Nplate Healthcare PDF Download PDF
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Nexium - PPI (Proton Pump Inhibitor) Healthcare PDF Download PDF
English
 
Nilandron Healthcare PDF Download PDF
English
 
Norditropin (Growth Hormone) Healthcare PDF Download PDF
English
 
Nutropin (Growth Hormone) Healthcare PDF Download PDF
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Nuvigil Healthcare PDF Download PDF
English
 
Omeprazole - PPI (Proton Pump Inhibitor) Healthcare PDF Download PDF
English
 
Omnitrope (Growth Hormone) Healthcare PDF Download PDF
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Orencia Healthcare PDF Download PDF
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Orthovisc Healthcare PDF Download PDF
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Pegasys Healthcare PDF Download PDF
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Peg-Intron Healthcare PDF Download PDF
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Penlac Healthcare PDF Download PDF
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Prialt Healthcare PDF Download PDF
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Provigil Healthcare PDF Download PDF
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Prevacid - PPI (Proton Pump Inhibitor) Healthcare PDF Download PDF
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Promacta Healthcare PDF Download PDF
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Prilosec - PPI (Proton Pump Inhibitor) Healthcare PDF Download PDF
English
 
Protonix - PPI (Proton Pump Inhibitor) Healthcare PDF Download PDF
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Prolastin Healthcare PDF Download PDF
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Procrit Healthcare PDF Download PDF
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Rebetol Healthcare PDF Download PDF
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Rebetron Healthcare PDF Download PDF
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Roferon A Healthcare PDF Download PDF
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Rebif (multiple sclerosis) Healthcare PDF Download PDF
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Remicade Healthcare PDF Download PDF
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Revlimid Healthcare PDF Download PDF
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Remodulin Healthcare PDF Download PDF
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Revatio Healthcare PDF Download PDF
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Reclast Healthcare PDF Download PDF
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Relistor Healthcare PDF Download PDF
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RibaPak Healthcare PDF Download PDF
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Ribasphere Healthcare PDF Download PDF
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Ribavirin Healthcare PDF Download PDF
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RibTab Healthcare PDF Download PDF
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Rituxan Healthcare PDF Download PDF
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Saizen (Growth Hormone) Healthcare PDF Download PDF
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Sancuso Healthcare PDF Download PDF
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Sandostatin Healthcare PDF Download PDF
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Sandostatin LAR Healthcare PDF Download PDF
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Selzentry Healthcare PDF Download PDF
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Sensipar Healthcare PDF Download PDF
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Simcor Healthcare PDF Download PDF
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Simponi Healthcare PDF Download PDF
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Smoking Cessation (Commercial Only) Healthcare PDF Download PDF
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Soliris Healthcare PDF Download PDF
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Somatuline Healthcare PDF Download PDF
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Somavert Healthcare PDF Download PDF
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Soriatane Healthcare PDF Download PDF
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Sporanox Healthcare PDF Download PDF
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Sprycel Healthcare PDF Download PDF
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Supartz Healthcare PDF Download PDF
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Sutent Healthcare PDF Download PDF
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Synvisc Healthcare PDF Download PDF
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Symlin Healthcare PDF Download PDF
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Synagis Order Form Healthcare PDF Download PDF
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Tarceva Healthcare PDF Download PDF
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Targretin Healthcare PDF Download PDF
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Tasmar Healthcare PDF Download PDF
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Tekturna Healthcare PDF Download PDF
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Tev-Tropin (Growth Hormone) Healthcare PDF Download PDF
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Thalomid Healthcare PDF Download PDF
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Tobi Healthcare PDF Download PDF
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Tysabri Healthcare PDF Download PDF
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Trilipix Healthcare PDF Download PDF
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Tasigna Healthcare PDF Download PDF
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Torisel Healthcare PDF Download PDF
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Treanda Healthcare PDF Download PDF
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Tykerb Healthcare PDF Download PDF
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Tracleer Healthcare PDF Download PDF
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Trelstar Healthcare PDF Download PDF
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Universal Fax Form Healthcare PDF Download PDF
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Valcyte Healthcare PDF Download PDF
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Velcade Healthcare PDF Download PDF
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Ventavis Healthcare PDF Download PDF
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Vectibix Healthcare PDF Download PDF
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Virazole Healthcare PDF Download PDF
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Viadur Healthcare PDF Download PDF
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Visudyne Healthcare PDF Download PDF
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Vidaza Injection Healthcare PDF Download PDF
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Vivitrol Healthcare PDF Download PDF
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Xolair Healthcare PDF Download PDF
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Xyzal Healthcare PDF Download PDF
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Xenazine Healthcare PDF Download PDF
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Zetia Healthcare PDF Download PDF
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Zolinza Healthcare PDF Download PDF
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Zometa Healthcare PDF Download PDF
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Zyvox Healthcare PDF Download PDF
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Zegerid - PPI (Proton Pump Inhibitor) Healthcare PDF Download PDF
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Zemaria Healthcare PDF Download PDF
English
 
Zorbtive (Growth Hormone) Healthcare PDF Download PDF
English
 
Zoladex Healthcare PDF Download PDF
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