Medicare AdvantagePrior AuthMedium impact
Quantity Limitation (Revised)
Humana·KY, SC, OH, IN, OK, VA·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana has revised its Quantity Limitation (QL) pharmacy coverage policy effective July 1, 2026, clarifying how quantity limits are applied across Medicare and multiple state Medicaid programs. The policy standardizes QL criteria based on FDA-approved dosing, medical literature, and treatment guidelines, and establishes a formal exception process for members requiring higher quantities due to dosage titration, documented medical literature support, treatment failure, or individual member characteristics. Billing teams must ensure prior authorization requests for quantity limit exceptions include appropriate clinical documentation to support approval.
Action Required
By July 1, 2026: Billing and prior authorization teams must update their processes to align with the revised QL exception criteria. Specifically: (1) When submitting QL exception requests for any medication, include supporting documentation such as FDA-approved dosing justification, peer-reviewed literature, evidence of treatment failure, or prescriber-documented individual member characteristics; (2) Update authorization templates and checklist systems to capture these four exception categories; (3) Train clinical staff that QL exceptions are approved only through end of plan year and require renewal; (4) Ensure providers understand that QL denials can be appealed with appropriate clinical documentation. Failure to submit proper supporting documentation will result in denial of QL exception requests and potential claim rejections.