Medicare AdvantagePrior AuthMedium impact
Previous Treatment/Prior Therapy/Trial (Revised)
Humana·FL, SC, IN, OK, VA · Pharmacy·Medicaid
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
Humana revised its Prior Therapy/Previous Treatment/Trial guidance policy (effective 1/1/2020, revised 10/22/2025) clarifying that a SINGLE pharmacy claim can demonstrate prerequisite therapy requirements across Medicare and multiple Medicaid state plans (FL, SC, IN, OK, VA). A single claim—typically 28-30 days but potentially shorter for appropriate drug classes like antibiotics/analgesics—now satisfies step therapy requirements unless a specific shorter timeframe is defined in drug-specific clinical policies. Prescriber documentation of medication failure is also now explicitly acceptable. This is a GUIDANCE policy affecting claim approval workflows.
Action Required
By November 15, 2025: Billing team and pharmacy staff must update Prior Authorization workflows to reflect that ONE pharmacy claim (regardless of supply days in some cases) satisfies prerequisite therapy requirements. Immediately review all active prior auth criteria templates and clinical policy decision trees to remove requirements for multiple claims or extended trial periods. Update eligibility verification and PA request forms to accept single-claim documentation of previous treatment/trial/prior therapy. Coordinate with providers to document prescriber attestation of medication failure when applicable instead of denying based on insufficient trial history. Verify that billing system approval rules align with state-specific timelines (no requirement unless clinical policy specifies). Flag any member denied within last 90 days under old multi-claim standards for appeal consideration. Failure to implement may result in unnecessary claim denials and provider appeals.