Medicare AdvantagePrior AuthMedium impact
Formulary Tier Exception (Revised)
Humana·Pharmacy·Pharmacy
Effective date
Feb 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Medicare Part D Formulary Tier Exception policy (effective 1/1/2019, revised 2/25/2026) to clarify the process for approving non-preferred drugs at lower cost-sharing tiers. Key clarification: when a tier exception is approved, the member pays the cost-sharing of the LOWEST applicable tier for that drug class (brand-to-brand, biologic-to-biologic, or generic-to-generic/brand), not the higher tier. Specialty tier drugs remain ineligible for tier exceptions. Billing teams must ensure prior authorization requests include physician supporting statements documenting medical necessity.
Action Required
By February 25, 2026: Pharmacy and billing teams must update tier exception adjudication logic to ensure approved exceptions are assigned the LOWEST applicable cost-sharing tier for the drug category (brand, biologic, or generic), not the requested higher tier. Update denial procedures to clearly communicate that tier exceptions cannot be granted for specialty-tier drugs or non-formulary drugs. Verify that prescriber supporting statements on file document why lower-tier alternatives would be ineffective or cause adverse effects before approving any tier exception request. Flag any tier exception requests lacking physician supporting statements and deny for lack of medical necessity with written explanation to member. Train appeals staff on CMS guidance that physician statements receive 'great weight' but do not guarantee automatic approval. Implement system checks to prevent tier exception requests for specialty-tier drugs and drugs already approved under non-formulary exceptions.