Prior authorization for pharmacy drugs

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.

Submitting a request for prior authorization

Prescribers can submit their requests to Humana Clinical Pharmacy Review (HCPR) through the following methods:

Phone requests: 1-800-555-CLIN (2546)
Hours: 8 a.m. to 6 p.m. local time, Monday through Friday

Fax requests: Complete the applicable form below and fax it to 1-877-486-2621.

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)

Prescriber quick reference guide
This guide helps prescribers determine which Humana medication resource to contact for prior authorization, step therapy, quantity limits, medication exceptions, appeals and claims. It also provides applicable phone, fax and Web contact information.

Prescriber quick reference guide (0.2 MB)

Commonly requested fax forms

Multisource brand (MSB) drug authorization form
Use this fax form to request use of brand medications that have a generic equivalent available.

Multisource brand (MSB) drug authorization form (0.5 MB)

Nonformulary drug authorization form
Use this fax form to request use of medications not on the member's formulary.

Nonformulary drug authorization form (190 KB)

High-risk medications form
Use this fax form to request use of medications identified by the Beers criteria as potentially high risk and inappropriate for use in the elderly.

High-risk medications form (206 KB)

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.

Forms for state mandates

Universal form for state mandates
The use of this form is mandated for prior authorization requests concerning commercial fully insured members who:

  • reside in Arkansas, Mississippi and Louisiana and/or
  • whose prescription drug coverage was sold in a state listed above

State-specific prior authorization request form

California authorization form
The use of this form is mandated for prior authorization requests concerning commercial fully insured members who:

  • reside in the state of California and/or
  • whose prescription drug coverage was sold in the state of California

Prescription drug prior authorization request form

If you have questions about whether you should use the state-mandated forms above, please call HCPR at 1-800-555-CLIN (2546).

Fax forms for specific drugs

Buprenex
(400 KB) Download PDF
English

Byetta
(400 KB) Download PDF
English

Calcitriol
(149 KB) Download PDF
English

Enbrel
(400 KB) Download PDF
English

Exjade
(400 KB) Download PDF
English

Flector
(400 KB) Download PDF
English

Hectorol
(149 KB) Download PDF
English

Humira
(400 KB) Download PDF
English

Janumet
(400 KB) Download PDF
English

Janumet XR
(209 KB) Download PDF
English

Januvia
(400 KB) Download PDF
English

Juvisync
(114 KB) Download PDF
English

Letairis
(400 KB) Download PDF
English

Lidoderm
(400 KB) Download PDF
English

Revatio
(400 KB) Download PDF
English

Revlimid
(400 KB) Download PDF
English

Subutex
(400 KB) Download PDF
English

Suboxone
(400 KB) Download PDF
English

Tarceva
(400 KB) Download PDF
English

Tracleer
(400 KB) Download PDF
English

Victoza
(144 KB) Download PDF
English

Xifaxan
(400 KB) Download PDF
English

Zemplar
(149 KB) Download PDF
English

Zubsolv
(400 KB) Download PDF
English

Universal fax forms for other requests

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

Universal fax form (110 KB)

Medicare coverage determination form

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

Request for coverage determination - English (0.5 MB)

Request for coverage determination - Spanish (0.5 MB)

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 CMS coverage determination request form.

Please note the following regarding medically accepted indications:
All reasonable efforts have been made to ensure consideration of medically accepted indications in Humana's prior authorization policies. 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