MedicaidPrior AuthHigh impact
Medical Necessity Determinations (Revised)
Humana·LA · Pharmacy·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana has revised its Medical Necessity Determinations policy for Louisiana Medicaid pharmacy coverage, effective January 1, 2023, with a revision date of November 26, 2025. The policy establishes a hierarchical framework for medical necessity review (state/federal requirements → Prime Therapeutics criteria → Humana criteria → approved compendia) and explicitly excludes experimental, non-FDA approved, investigational, and cosmetic services from coverage. This is a guidance document that standardizes how prior authorization and medical necessity decisions are made for pharmacy products.
Action Required
Immediately: Billing and prior authorization teams must implement the hierarchical medical necessity review criteria for all Louisiana Medicaid pharmacy requests in this order: (1) state/federal regulatory requirements, (2) Prime Therapeutics drug-specific clinical criteria, (3) Humana drug-specific clinical criteria, (4) approved compendia. All pharmacy requests must be screened against the exclusion criteria (experimental, non-FDA approved, investigational, or cosmetic uses) and denied as not medically necessary if they fall into these categories. Before processing any pharmacy prior authorization for Louisiana Medicaid members, verify that the requested medication and indication meet these criteria through the sources listed in priority order. Update internal workflows and staff training to reference these four criteria tiers. Update any billing software or prior authorization systems to flag non-compendia-supported indications as likely exclusions. Ensure all denial letters cite the specific exclusion criteria when denying experimental or investigational uses. Failure to apply these criteria consistently will result in inappropriate approvals and potential recovery actions by Humana.