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.

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.

Fax forms for specific drugs

Abilify
(174 KB) Download PDF
English

Advair
(204 KB) Download PDF
English

Aranesp
(223 KB) Download PDF
English

Byetta
(203 KB) Download PDF
English

Cymbalta
(176 KB) Download PDF
English

Enbrel
(209 KB) Download PDF
English

Flector
(204 KB) Download PDF
English

Humira
(211 KB) Download PDF
English

Janumet
(204 KB) Download PDF
English

Janumet XR
(204 KB) Download PDF
English

Januvia
(203 KB) Download PDF
English

Kombiglyze XR (Medicare)
(This fax form is for Medicare members only.)
(169 KB) Download PDF
English

Kombiglyze XR (non-Medicare)
(This fax form is for non-Medicare members.)
(200 KB) Download PDF
English

Lidoderm
(90 KB) Download PDF
English

Lovenox
(209 KB) Download PDF
English

Lupron
(219 KB) Download PDF
English

Lyrica
(207 KB) Download PDF
English

Neupogen
(221 KB) Download PDF
English

Onglyza (Medicare)
(This fax form is for Medicare members only.)
(169 KB) Download PDF
English

Onglyza (non-Medicare)
(This fax form is for non-Medicare members.)
(200 KB) Download PDF
English

Procrit
(224 KB) Download PDF
English

Revatio
(175 KB) Download PDF
English

Revlimid
(182 KB) Download PDF
English

Suboxone
(173 KB) Download PDF
English

Subutex
(173 KB) Download PDF
English

Tracleer
(170 KB) Download PDF
English

Victoza
(203 KB) Download PDF
English

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.