Smart Maintenance Dose (Revised)

By September 24, 2025: Billing and clinical teams must implement the following: (1) Alert all prescribing providers that Humana will apply automatic dosing edits at point-of-sale for specialty drugs with loading and maintenance phases; (2) Establish a process for providers to submit clinical justification and dosing rationale when prescribing doses exceeding the maintenance dose—documentation must be provided at time of claim submission; (3) Update billing software and prior authorization workflows to flag specialty drug claims exceeding maintenance doses for manual clinical review rather than auto-denying; (4) Train billing staff to recognize which specialty drugs are subject to SMD edits and to communicate to providers that claims without adequate clinical justification will be held; (5) Communicate to providers that approval duration is through end of plan year or as determined by clinical review. Failure to provide clinical rationale will result in claim holds and denials. Reference Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for specific affected drugs.