Provider Authorisation Pr

Puerto Rico prior authorization

Certain drugs require prior authorization (PA) or a medical exception for coverage. For these medications, a request needs to be submitted to and approved by Humana before the drug may be covered by the member’s health plan.

Prior authorization for pharmacy drugs

For pharmacy drugs, prescribers can submit their requests to Humana Clinical Pharmacy Review (HCPR) — Puerto Rico through the following methods:

Phone requests: 1-866-488-5991
Hours: 8 a.m. to 6 p.m. local time, Monday through Friday

Fax requests: Complete the applicable form below and fax it to 1-855-681-8650. To submit a request for a professionally administered drug, see the information at the bottom of this Web page.

Electronic requests: CoverMyMeds® is a free service that allows prescribers to submit and check the status of prior authorization requests electronically for any Humana plan. Visit www.covermymeds.com to use this service (registration required) or review the flier below for details.

CoverMyMeds overview flier (329 Kb)

Puerto Rico prescriber quick reference guide - English (42Kb)
This guide helps prescribers determine which Humana medication resource to contact for prior authorization, step therapy, quantity limits, medication exceptions, appeals, precertification and claims. It also provides applicable phone, fax and Web contact information.

Commonly requested fax forms for specific situations

High-risk medications (HRM) form - English (205Kb)

Use this fax form to request use of medications identified by the Beer’s criteria as potentially high risk and inappropriate for use in the elderly.

Before submitting a prior authorization request for an elderly patient, please review this list of medications to avoid in the elderly. It is adapted from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) measure, Use of High-Risk Medications in the Elderly.

Brand-name multisource authorization (MSB) form - English (184Kb)
Use this fax form to request use of brand-name medications that have a generic equivalent available.

Nonformulary drug authorization form - English (201Kb)
Use this fax form to request use of medications not on the member’s formulary.

Hospice medications (129 Kb)
Use this fax form to request use of hospice medications.

Universal fax forms

If a specific fax form for the medication being requested is not located above, please use the universal fax form below.

Universal fax form - English (200Kb)

Medicare coverage determination forms

Request for coverage determination (also known as prior authorization form)

Request for coverage determination - English (189Kb)

Request for coverage determination - Spanish (131Kb)

If you prefer, you may complete the coverage determination request form online. Before completing the form, you may want to view our accepted file types.

Another option is to use the coverage determination request form on the CMS website.

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 the Centers for Medicare & Medicaid Services (CMS) as those uses of a covered Part D drug that are approved under the Social Security 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:

  • American Hospital Formulary Service (AHFS) Compendium
  • Thomson Micromedex/DrugDex (not Drug Points) Compendium
  • National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium
  • Elsevier Gold Standard's Clinical Pharmacology Compendium

Prior authorization for professionally administered drugs

Some drugs require prior authorization before they can be delivered or administered in a physician's office, clinic, outpatient or home setting.

Prescribers should submit these requests to the Puerto Rico Medication Intake Team by fax at 1-800-594-5309 (Medicare requests) or 1-800-658-9457 (commercial requests).

Prescribers with questions about the prior authorization process for professionally administered drugs should call
1-866-488-5995 for Medicare requests and 1-800-314-3121 for commercial requests. Assistance is available Monday through Friday, 8:30 a.m. to 5:30 p.m. local time.

To view a list of drugs for which Humana requires prior authorization, see the applicable preauthorization and notification list.