Prior authorization

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 Humana Drug List.

• Medicare Drug List
• Employer Drug List

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.

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

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:
   • Submit an online request for Part D prior authorization
   • Download, fill out and fax one of the following forms to 877-486-2621:
     • Request for Medicare Prescription Drug Coverage Determination – English , PDF
     • Request for Medicare Prescription Drug Coverage Determination – Spanish, PDF
   • Call 800-555-CLIN (2546), Monday – Friday, 8 a.m. – 8 p.m., local time.

Note: 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 above to 855-681-8650.