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HumanaMedicaid · Prior Auth · Pharmacy · LA · PharmacyHigh impact

Drug Utilization Management and Clinical Edits Tools (New)

Effective date
Oct 1, 2025
Identified
Sep 23, 2026

Summary

This new Humana Medicaid-Louisiana pharmacy policy (effective October 1, 2025) establishes Drug Utilization Management (DUM) and clinical editing tools including prior authorization, step therapy, quantity limits, accumulation edits, duplication edits, and drug/age/gender/disease/drug-drug/pregnancy edits. The policy applies clinical edits at point-of-service for safety and cost-effectiveness, with grandfathering provisions for specific drug classes (antidepressants, antipsychotics, anticonvulsants, antineoplastics, antiretrovirals, and immunosuppressants). Billing teams must prepare for increased pharmacy claim rejections and prior authorization requirements.

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What to do

Action · 10 steps
01REQUIREMENTS: By October 1, 2025: Billing and pharmacy teams must: 1.
02Update billing system configuration to implement electronic clinical edits at point-of-service for all pharmacy claims on Louisiana Medicaid plans, including: prior authorization requirements, step therapy protocols, quantity limits, accumulation edits, duplication edits, and drug/age/gender/disease/drug-drug/pregnancy edits 2.
03Establish prior authorization workflow procedures for non-grandfathered medications and communicate to prescribers 3.
04Train front-desk and billing staff to communicate to patients that certain pharmacy claims may require prior authorization before dispensing 4.
05Document which drug classes are grandfathered (currently: antidepressants for behavioral health, antipsychotics, anticonvulsants for epilepsy, antineoplastics, antiretrovirals, immunosuppressants for transplant prophylaxis) and ensure these receive expedited approval 5.
06Implement appeals process for members stable on therapy using diagnosis, coverage limitations, disease progression, and ECOG criteria 6.
07Flag drug samples as NOT qualifying as treatment experience for step therapy/PA requirements—prior sample use does not waive new-start restrictions 7.
08Update claim submission procedures to include required medical records for appeals Consequences: Claims will be denied at point-of-service without proper prior authorization or step therapy completion.
09Members may experience pharmacy delays.
10Non-compliance will result in increased claim denials and member complaints.

Original notice

Drug Utilization Management and Clinical Edits Tools (New)
mcp.humana.com · Always check the source before changing claims.
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Related changes

See all Humana changes →
Drug Utilization Management and Clinical Edits Tools (Revised)HighNo effective date · PharmacyDrug Utilization Management and Clinical Edits Tools (Revised)MediumEffective Aug 28, 2010 · PharmacyDrug Utilization Management and Clinical Edits Tools (New)HighEffective Oct 1, 2025 · PharmacyBrowse every Humana change in the policy list

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