MedicaidAdministrativeMedium impact
Non-Preferred Exceptions (Revised)
Humana·FL, SC, VA · Pharmacy·Medicaid
Effective date
Aug 6, 2025
We identified it
Jun 25, 2026
Summary
This is a refreshed guidance policy (revised August 6, 2025) clarifying Humana's non-preferred pharmacy exception procedures for Medicaid members in Florida, South Carolina, and Virginia. The policy establishes a 24-hour decision timeframe for non-preferred drug exception requests submitted via phone, fax, or electronic prior authorization, with approved exceptions valid for up to one year. No substantive changes from the original January 1, 2020 effective date are documented—this appears to be a routine policy republication.
Action Required
By September 6, 2025: Billing and clinical pharmacy teams must review and confirm current workflows align with this revised policy. Specifically: (1) Verify that the HCPR call center processes non-preferred exception requests (oral, fax, e-PA) and documents all communications in electronic case files; (2) Ensure prescribers are informed that written requests are preferred and will receive decisions within 24 hours; (3) Confirm that when oral requests are received, call center staff document completely and read back information to prescribers for verification; (4) Verify that requests lacking sufficient information to demonstrate medical necessity (per the three clinical criteria outlined) are denied with guidance to resubmit through appeals; (5) Update internal tracking to reflect that approved exceptions are valid for 1 year and do not require reapproval for refills if the member remains enrolled and the prescriber continues to prescribe. Contact Humana Clinical Pharmacy Review (HCPR) to validate processes. Failure to maintain these procedures may result in delayed member access to medically necessary non-preferred drugs and potential compliance violations.