Medicare AdvantagePrior AuthMedium impact
Drug Utilization Management and Clinical Edits Tools (Revised)
Humana·FL, SC, IN, OK, VA · Pharmacy·Pharmacy
Effective date
Aug 28, 2010
We identified it
Jun 25, 2026
Summary
This is a guidance policy update (revised November 26, 2025) that clarifies Humana's Drug Utilization Management and Clinical Edits Tools across Medicare and multiple state Medicaid programs. The policy outlines how Humana applies prospective clinical edits (prior authorization, quantity limits, step therapy, duplication edits, drug/drug interactions, accumulation edits, and age/gender/disease/pregnancy edits) to ensure safe and cost-effective medication therapy. The policy specifies grandfathering exceptions for four drug classes (antidepressants, antipsychotics, anticonvulsants for epilepsy, antineoplastics, antiretrovirals, and immunosuppressants) and clarifies that drug samples do not count as treatment experience for prior authorization or step therapy requirements.
Action Required
REQUIREMENTS: By December 31, 2025 (to align with new plan year implementation): Billing and pharmacy teams must review and update their prior authorization and step therapy protocols to reflect Humana's clinical edit tools as described in this revised guidance. Specifically: (1) Ensure PA/ST systems accurately distinguish between grandfathered drug classes (antidepressants, antipsychotics, anticonvulsants for epilepsy, antineoplastics, antiretrovirals, immunosuppressants) and non-grandfathered drugs; (2) Configure systems to reject claims for new starts on non-grandfathered drugs requiring PA/ST—drug sample history does NOT override this requirement; (3) Update prior authorization request forms to document whether the member is a 'new start' or 'treatment-experienced'; (4) Train prior authorization staff that drug samples are NOT evidence of treatment experience for the requested drug; (5) For members stable on grandfathered medications, ensure approval processes review diagnosis, coverage limitations, disease progression, and ECOG staging as appropriate. Consequences of inaction: Claims will be denied for new starts on non-grandfathered drugs without prior authorization, and appeals will be denied if drug sample history is cited as evidence of treatment experience. This affects all prescription drug claims submitted to Humana Medicare Advantage and Medicaid plans in FL, SC, IN, OK, and VA.