Medicare AdvantagePrior AuthMedium impact
Non-Formulary Exceptions (Revised)
Humana·Pharmacy·Pharmacy
Effective date
Jan 1, 2019
We identified it
Jun 25, 2026
Summary
This is a revision to Humana's Non-Formulary Exceptions policy for Medicare Part D coverage, effective January 1, 2019, with the most recent revision dated June 24, 2026. The policy establishes procedures for members and physicians to request coverage of prescription drugs not included on Humana's formulary, with decision timeframes of 72 hours standard (24 hours expedited) and specific requirements for physician supporting statements. Key updates clarify that approved exceptions remain valid for the remainder of the plan year without requiring refill reauthorization, and Humana may limit days' supply to one month for specialty medications, opioids, and benzodiazepines.
Action Required
REQUIREMENTS: By January 1, 2026 (if not already implemented): Pharmacy billing and clinical teams must ensure workflows align with the following: (1) Accept non-formulary exception requests via phone (Humana Clinical Pharmacy Review call center), fax, email, and web portals from members, member representatives, and prescribers; (2) Document all requests (oral and written) in member electronic case files; (3) Process requests within 72 hours standard or 24 hours expedited from receipt of physician supporting statement; (4) If no decision is communicated within the applicable timeframe, automatically forward case to independent review entity (IRE) and notify member within 24 hours of deadline expiration; (5) Recognize that once an exception is granted for a non-formulary drug, refills and new prescriptions do NOT require resubmission during the same plan year if prescriber continues to prescribe and drug remains safe; (6) Limit days' supply of approved exceptions to one-month per fill for specialty drugs, opioids, and benzodiazepines; (7) Train clinical pharmacy staff that physician supporting statements carry great weight and must demonstrate one of three factors: formulary alternatives are less effective or cause adverse effects, dose restrictions are ineffective/harmful, or step therapy requirements are ineffective or harmful. Update internal tracking systems to flag exceptions approved near plan year-end so resubmission is not incorrectly required in the new plan year. Consequences: Failure to meet 72/24-hour timeframes constitutes an adverse decision and triggers automatic IRE referral. Improper denial of exception requests may result in member appeals and regulatory scrutiny from CMS.