CommercialPrior AuthMedium impact
Contraceptive Medications (Revised)
Humana·OB-GYN, Dermatology, Endocrinology +3 more·Commercial
Effective date
Feb 28, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its Contraceptive Medications prior authorization policy (effective February 28, 2024) for commercial plans. The policy clarifies that contraceptives require prior authorization when medically necessary for specific diagnoses (acne, amenorrhea, dysmenorrhea, endometriosis, PCOS, etc.) and establishes strict exclusion criteria including pregnancy, cancer history, cardiovascular disease, and smoking. Billing teams must ensure prior authorization is obtained before processing claims and verify member eligibility against the exclusion list.
Action Required
By March 15, 2024: Billing and clinical teams must implement prior authorization requirements for all contraceptive medication claims submitted to Humana commercial plans. Update billing system and encounter forms to: (1) Require documentation of medical necessity diagnosis (acne, amenorrhea, dysmenorrhea, endometriosis, PCOS, irregular menses, ovarian cyst, hirsutism, perimenopausal symptoms); (2) Screen claims against exclusion criteria before submission (pregnancy status, cancer history, cardiovascular disease, stroke, smoking, hepatic disease, renal disease, valvular heart disease, endometrial hyperplasia, undiagnosed vaginal bleeding); (3) Obtain prior authorization through Humana's PAL system before dispensing. Billing team must verify current policy at http://apps.humana.com/tad/tad_new/home.aspx before processing each claim. Claims submitted without prior authorization or with excluded diagnoses will be denied. Front-desk staff should flag contraceptive requests at intake to allow time for prior auth processing.