MedicaidAdministrativeMedium impact
Medical Necessity Determinations (Revised)
Humana·OH · Pharmacy·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana has updated its Medical Necessity Determinations policy for Ohio Medicaid pharmacy coverage, effective November 26, 2025. The policy clarifies the hierarchy for reviewing pharmacy requests: state/federal regulatory criteria first, then Pharmacy Benefit Manager (Gainwell) clinical criteria, followed by Humana clinical criteria, and approved compendia. Approval duration is set to the initial plan year for new requests and renewal plan year for renewals. This is a guidance document that standardizes how medical necessity reviews are conducted for pharmacy products.
Action Required
By November 26, 2025: Billing team must ensure pharmacy claim submission processes align with Humana's revised medical necessity review hierarchy for Ohio Medicaid members. When submitting pharmacy prior authorization requests, follow the criteria in this order: (1) ODM-developed criteria if available; (2) Gainwell drug-specific clinical criteria; (3) Humana drug-specific clinical criteria; (4) approved compendia. Verify all pharmacy claims include proper medical necessity documentation. Providers should understand that approval duration follows plan year timelines (initial plan year for new approvals, renewal plan year for renewals). Reference the Humana PAL portal at www.humana.com/PAL for preauthorization requirements. Non-compliant submissions may experience delays or denials.