Request for coverage determination (also known as prior authorization form)
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 Federal Food, Drug and Cosmetic 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 reviews 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: