Humana Prior (Rx) Authorization Form

Updated December 31, 2021

A Humana Prior Authorization Form is filled out by a pharmacist in order to help a patient secure coverage for a certain medication. By submitting this form, the pharmacist may be able to have the medication covered by Humana. In your form, you will need to explain your rationale for making this request, including a clinical justification and referencing any relevant lab test results.

By State

How to Write

Step 1 – Enter the patient’s full name, their member number, their group number, their complete address.

Step 2 – Next, provide the prescriber’s name, fax number, phone number, office contact name, NPI number, Tax ID number, complete address, and specialty/facility name.

Step 3 – Indicate if this is a request for a new plan year and, if so, provide the plan year.

Step 4 – If this is an urgent request, check the appropriate box and explain why it is urgent.

Step 5 – Enter the patient’s height, weight, and allergies (if applicable).

Step 6 – Provide the J-code, drug name, dose, and directions for use for the requested drug(s).

Step 7 – Supply the diagnosis, J-code, and ICD diagnostic codes.

Step 8 – Use the checkboxes or blank fields to provide your answer to each of the following:

  • Is this drug for an ongoing investigational trial?
  • What is the location of the treatment?
  • Is this a reauthorization request?
  • Is the patient currently stable on therapy?
  • What are all previously tried therapeutic alternatives and their outcome?
  • Provide all relevant lab results related to the patient’s diagnosis
  • If the request is a duplicate provide your rationale
  • Provide rationale for requested quantity
  • Provide patient’s complete medication list
  • Provide all pertinent medical information relevant to patient’s diagnosis
  • Include any additional comments that support your request

Step 9 – Provide your signature and the date.