MedicaidPrior AuthMedium impact
Continuity of Care (Revised)
Humana·OH · Pharmacy·Medicaid
Effective date
May 27, 2026
We identified it
Jun 25, 2026
Summary
Humana has revised its Continuity of Care policy for Ohio Medicaid pharmacy coverage, effective May 27, 2026. The policy allows overrides of utilization management (step therapy, prior authorization, non-preferred edits) for patients stable on pre-existing medications within 90 days of eligibility, but excludes experimental/investigational uses, off-label uses without evidence, and certain high-risk medication categories. Billing teams must implement validation logic to ensure requests meet all three criteria and flag exclusions before approving claims.
Action Required
By May 27, 2026: Billing and prior authorization teams must update pharmacy claim review procedures for Ohio Medicaid members. Implement three-point validation: (1) Verify member is stable on requested medication with documented clinical evidence, (2) Confirm diagnosis is compendia-supported (check CMS-recognized compendia or peer-reviewed literature), (3) Confirm member eligibility start date is within 90 days of request. For all three criteria met, override step therapy, prior auth, and non-preferred edits in billing system. CRITICAL EXCLUSIONS: Do NOT override for experimental/investigational indications, off-label uses lacking evidence support, medications on SSA Title 19 exclusion list (high fraud/abuse potential), or non-preferred generics with preferred AB-rated brand alternatives. Claims for off-evidence or off-label uses must be denied. Update pharmacy claim submission templates and prior auth decision trees. Train all staff involved in Ohio Medicaid pharmacy authorizations. Failure to apply exclusions may result in claim rejections and compliance violations.