Prior Authorization

Some medicine requires approval from Humana

Before filling a prescription, you may need to get approval from Humana first to make sure the medicine is covered under your insurance plan. This is called “prior authorization.”

If your medicine requires prior authorization and you fill your prescription without getting approval, you could be responsible for all expenses associated with the medicine.

AZ, CO, TX and TN residents: If you filled a prescription that required prior authorization and did not receive approval from Humana in advance, you may be eligible for reimbursement. In order to seek reimbursement, please download and complete the Prescription Drug Claim Form (link opens in new window) and send it to us.

It’s important to have the right treatment

Here’s an example of prior authorization: you have diabetes and your doctor wants you to try a new medicine. This medicine requires approval from Humana before you can fill the prescription.

Reasons why you may need approval include:

  • There is a state or federal mandate that requires Humana to review prescription requests
  • There is lower-cost alternative medicine that treats the same condition
  • The medicine may have side-effects or require special monitoring
  • The medicine may be dangerous if taken with another medicine you’re taking
  • The medicine should only be taken for certain health conditions
  • The medicine is a controlled substance or is more likely to be abused or misused

To see which medicine requires prior authorization, search Humana's Drug List.

Getting your medicine approved

If you learn your medicine needs approval, your doctor will need to contact Humana Clinical Pharmacy Review (HCPR) and submit a prior authorization request. Here are the options:

If you don’t agree with Humana’s decision

You may be able to appeal Humana’s decision if your medicine is not approved. To file an appeal, please download and complete the Grievance and Appeal Request Form (link opens in new window) and return it to us.

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