Humana Changes for 2019: Preauthorization, Notification, and Formularies
By Ellen Terry

Contract_Etip

Humana has made changes for 2019 to its preauthorization and notification lists. Preauthorization is now required for these procedures: 

  • Peripheral revascularization (atherectomy, angioplasty), ablation (bone, liver, kidney, prostate), and thyroid surgeries (thyroidectomy and lobectomy) for commercial fully insured, Medicare Advantage, and dual Medicare-Medicaid plans. (HealthHelp will review requests.) See the Humana surgical services and ablation webpages for details.
  • Capsule endoscopy and noninvasive home ventilators for commercial fully insured, Medicare Advantage, and dual Medicare-Medicaid plans. (Humana will review requests.)
  • Decompression of peripheral nerve (i.e., carpal tunnel surgery), EGD endoscopy (patients 59 and younger only; includes site-of-service evaluation), and gastric pacing for commercial fully insured plans. (Humana will review requests.) 

Changes Affecting Drugs

  • Preauthorization for medications delivered in the physician’s office, clinic, outpatient or home setting now applies to all medications noted with an asterisk (*) on the preauthorization lists posted on Humana.com/PAL.
  • Certain drugs have new limitations or require utilization management (e.g., prior authorization requirements, step therapy modifications, and nonformulary changes) under the Humana Medicare formularies for the 2019 plan year.
    For example, Humana will require review of some injectable drugs and biologics for step therapy in addition to current review requirements. The affected drugs and biologics are indicated on Humana’s preauthorization and notification lists for its commercial, Medicare Advantage, and dual Medicare-Medicaid plans with a hashtag (#). (The Centers for Medicare & Medicaid Services has rescinded a September 2012 memo that prohibited Medicare Advantage plans from applying step therapy for physician-administered and other Part B drugs.)

For details, visit the Humana drug lists webpage.

Source: Humana

The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed. Publishing this news or these excerpts does not imply that TMA supports or approves of the changes announced or discussed.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.

Last Updated On

February 27, 2019

Related Content

Humana | Insurance

Ellen Terry

Project Manager, Client Services

(512) 370-1391

Ellen Terry has been writing, editing, and managing communication projects at TMA since 2000. She hails from Victoria, Texas; has a journalism degree from Texas State University; and loves to read great fiction. Ellen and her husband have two grown sons and a couple of cats.

More stories by Ellen Terry