Prior authorization
Two gentleman sitting on a park bench enjoying conversation and each other’s company.

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.”

How prior authorization works

Let’s say you have diabetes and your doctor wants you to try a new diabetes medication. The medication your doctor prescribed may be on Humana’s list of drugs that requires prior authorization.

To see which medication requires prior authorization, search Humana's 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.

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

You can start a prior authorization request or ask your doctor to contact Humana Clinical Pharmacy Review (HCPR) for approval.

Here are the ways your doctor can request approval:

If you don’t agree with Humana’s decision

You may be able to appeal Humana’s decision if your medication is not approved. To file an appeal, please download and complete the grievance and appeal request form and return it to us.

Medicare Grievances and Appeals Request Form, PDF opens new window

Employer Grievances and Appeals Request Form, PDF opens new window

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 and send it to us.

Medicare coverage policies and claim forms

View documents regarding our prescription coverage policies, reimbursement and claim forms for Medicare.