Medicare AdvantagePrior AuthMedium impact
Quantity Limitation (Revised)
Humana·SC, IN · Pharmacy·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Quantity Limitation (QL) guidance policy for pharmacy coverage effective November 26, 2025. This policy applies to Medicare and Medicaid (South Carolina and Indiana) and establishes standardized quantity limits across all therapeutic classes based on FDA-approved dosing, medical literature, and CMS guidance. The policy permits exceptions when members require dosage titration, have evidence-based support, have failed covered quantities, or when specific member characteristics warrant higher quantities. Billing teams must understand the exception criteria to properly handle prior authorization requests for quantities exceeding standard limits.
Action Required
By December 31, 2025: Billing and Prior Authorization teams must review and document the four exception criteria for quantity limit overrides in their internal procedures: (1) dosage titration to FDA-approved maximum, (2) dosage supported by pharmacy compendia or peer-reviewed literature, (3) member has failed the covered quantity, or (4) prescriber documentation showing individual member characteristics warrant higher quantity or compliance concerns. Update prior auth request templates and denial letter language to reference these four specific exceptions. Train staff handling quantity limit appeals to recognize and properly submit documentation supporting each exception type. Ensure that all initial and renewal QL approvals are processed through end of plan year per policy. Failure to properly document and submit exception criteria will result in claim denials for quantities exceeding limits.