MedicaidPrior AuthMedium impact
Medical Necessity Determinations (Revised)
Humana·KY · Pharmacy·Medicaid
Effective date
Dec 11, 2024
We identified it
Jun 24, 2026
Summary
Humana has updated its medical necessity determination criteria for Kentucky Medicaid pharmacy coverage, establishing new review standards that must be evaluated by licensed pharmacists or physicians using specific medical references and state regulations.
Action Required
Immediately: Billing team must ensure all Kentucky Medicaid pharmacy requests meet the new medical necessity criteria including compliance with 907 KAR 3:130 regulations. Update prior authorization request processes to reference required medical standards (AHFS-DI, NCCN, Micromedex, Clinical Pharmacology, UpToDate Lexi-Drugs). Prepare to provide additional clinical documentation when requested by Humana for medical necessity reviews.