Humana Updates Commercial Preauthorization and Notification List
On July 20, 2017, Humana will update its preauthorization and notification list for all commercial plans.
Changes to commercial preauthorization requirements include:
- Expansion of medication preauthorization requirements to include Aloxi, Feiba NF, Granix, Mozobil, Nuwiq, NovoEight, Kanuma, Nucala, Strensiq, Tretten and Vidaza. All other blood-clotting factors still require preauthorization.
- Additions to the list of drugs that require site-of-care review for commercial fully insured plans and exchanges. Previously, Humana established evidence-based guidelines for review of certain injectable or infusible drugs and biologics to determine the appropriateness of the outpatient hospital site of care. The list of drugs that require site-of-care review now include the following additions:
- Alpha 1 Proteinase Inhibitors
- Aralast NP (alpha-1 proteinase Inhibitor (human))
- Glassia (alpha-1 proteinase Inhibitor (human))
- Prolastin-C (alpha-1 proteinase Inhibitor (human))
- Zemaira (alpha-1 proteinase Inhibitor (human))
- Enzyme Replacement Drugs
- Aldurazyme (laronidase)
- Cerezyme (imiglucerase for injection)
- Elelyso (taliglucerase alfa)
- Fabrazyme (agalsidase beta)
- Lumizyme (alglucosidase alfa)
- Myozyme (alglucosidase alfa)
- Vpriv (velaglucerase alfa)
- Feiba NH (anti-inhibitor coagulant complex)
- NovoEight (turoctocog alfa)
- Nuwiq (simoctocog alfa)
- Tretten (factor XIII A-subunit, recombinant)
- Immune Globulin
- Bivigam (immune globulin)
- Carimune NF (immune globulin)
- Cuvitru (immune globulin)
- Flebogamma 5% (immune globulin)
- Gamastan (immune globulin)
- Gammagard S/D (immune globulin)
- Gammagard Liquid (immune globulin)
- Gammaked (immune globulin)
- Gammaplex (immune globulin)
- Gamunex (immune globulin)
- Hizentra (immune globulin)
- HyQvia (immune globulin)
- Octagam (immune globulin)
- Privigen (immune globulin)
- Vivaglobin (immune globulin)
- Actemra IV (tocilizumab)
- Entyvio (vedolizumab)
- Exondys 51 (eteplirsen)
- Inflectra (infliximab-dyyb)
- Orencia IV (abatacept)
- Prolia (denosumab)
- Remicade (infliximab)
- Simponi ARIA (golimumab)
- Soliris (eculizumab)
- Synagis (palivizumab)
- These medications will require additional information to allow Humana to consider approval for outpatient hospital-based services with Centers for Medicare & Medicaid Services (CMS)/American Medical Association (AMA) place-of-service codes 19 (off-campus outpatient hospital) and 22 (on-campus outpatient hospital).
- If a health care provider does not obtain preauthorization or bills for that site of care outside of that which was authorized, it may result in claim denial. Any denial will follow Humana’s standard processes.
Important note: Please note the term “preauthorization” (i.e., prior authorization, precertification, preadmission) when used in this communication is defined as a process through which the physician or other health care provider is required to obtain advance approval from the plan as to whether an item or service will be covered.
“Notification” refers to the process of the physician or other health care provider notifying Humana of the intent to provide an item or service. Humana does not require notification, but requests it, as this helps coordinate care for our members. This process is distinguished from preauthorization. Humana does not issue an approval or denial related to a notification.
Please note that urgent/emergent services do not require referrals or preauthorizations.
If a health care provider does not obtain preauthorization for a service, it could result in payment denials for the health care provider or reduced benefits for the member. Services or medications provided without preauthorization may be subject to retrospective medical necessity review. We recommend that a health care provider making a specific request for services or medications verify benefits and authorization requirements with Humana prior to providing services.
- Commercial HMO members: Health care providers who participate in an IPA or other risk network with delegated services are subject to the preauthorization list and should refer to their IPA or risk network for guidance on processing their requests. Exclusions may change; refer to Humana.com/provider for the most up-to-date information. Choose “Authorizations & Referrals” and then the appropriate topic.
- Humana Individual product members: The full list of Commercial Preauthorization and Notification List requirements applies to patients with individual Humana insurance products.
- Administrative-services-only (ASO) groups: It is important to note that some employer groups for which Humana provides administrative services only (self-insured, employer-sponsored programs) may customize their plans with different requirements.
You may view Humana’s preauthorization and notification lists and find information about the changes to these lists by visiting Humana’s website at Humana.com/PAL. You will find links to the current preauthorization and notification lists and other information. Humana will update the lists when new preauthorization requirements are added and when new drugs or technology enter the market.
If you do not have access to the web and you have questions about this information, or require a printed copy of the preauthorization lists, please contact a Humana customer care representative at 1-800-4HUMANA (1-800-448-6262), Monday through Friday, 8 a.m. to 6 p.m. local time.