Prior authorization

A woman uses a phone while referencing a booklet in her kitchen.

We want to make sure you have the right treatment for your condition, so there may be times when it is necessary to get approval from Humana before getting a prescription filled. This is called “prior authorization.”

Why is prior authorization required?

Select high-risk or high-cost medications require prior authorization by the Humana Clinical Pharmacy Review (HCPR) to be eligible for coverage. This is to ensure that the drugs are used properly and in the most appropriate circumstances.

To see which medication requires prior authorization, search the list of covered drugs for Medicare. 

Note: If your medication requires prior authorization and you fill your prescription without getting approval, you may be responsible for all expenses associated with the medication.

Why you may need approval

Here are some reasons you may need approval for your medication:

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

How to receive approval

To receive coverage for a medication requiring prior authorization, you can:

  1. Ask your healthcare provider to submit the request. Your healthcare provider can submit the request online, by fax or phone by accessing our provider's prior authorization information. Once your request has been processed, your healthcare provider will be notified. If you are a Medicare member, you will also receive a determination letter in the mail.
  2. Submit your own prior authorization request. You can complete your own request in 3 ways:

    For drug coverage requests in Puerto Rico, call 866-773-5959, Monday – Friday, 8 a.m. – 6 p.m., local time. You can also download, fill out and fax one of the forms below to 855-681-8650:

AZ, CO, TX and TN non-Medicare residents

If you filled a prescription that required prior authorization but did not receive approval from Humana in advance, you may be eligible for reimbursement for your out-of-pocket expense, less any cost share.For reimbursement, please download and complete the Prescription Drug Claim Form, PDF and send it to us by mail, fax or the PromptPA portal.