» » Humana Prior (Rx) Authorization Form

Humana Prior (Rx) Authorization Form

The Humana Prior Authorization Form is filled out by a pharmacist in order to secure coverage for a patient to acquire a certain medication when they otherwise would be unable to do so. 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.

Related pages

rental agreement utahstate of florida notary statementtemplate for llc operating agreementvirginia llc formationcontract termination letter sample freemd eviction processcolorado advance directives30 day notice to vacate california samplelease agreement printablesample of recommendation letter for a friendcattle land lease agreementsample letters of recommendation from friendindiana durable power of attorney formbasic sublease agreementrent stabilized lease formsimple tenant lease agreementeviction laws in north carolinamvt 5-13mississippi boat registrationbbt direct depositbeneficiary deed formpersonal guaranty agreementtennessee quit claim deedfedex blank commercial invoicest charles county recorder of deeds missouriflorida dept of revenue formssamples of promissory notejdf online sign upinvoice template for cleaning servicesrental receipts pdfequine sales contractloan agreement template free wordca assn of realtorsdefine quit claim deedcontractor receipt template freetemplate acknowledgement of debtregister boat coloradotemplate willseagle scout reference letter exampleincreasing rent letter to tenantquit claim deed wapaychex direct depositflorida residential lease agreement wordminnesota guardianship formswills motor sales30 day notice to vacate virginiahow to write an eviction notice to a tenantmn deedpower of attorney revocation letternotice to vacate letter californiaroom rental contract templatequit claim deed louisianasample llc operating agreement templatealabama advance directive for health caretemplate for 30 day notice to landlordlandlord notice to vacate letter to tenantletter of eviction templatepromissory note illinoissample of contractor invoice3 day notice to pay or quit form californianj eviction noticedurable power of attorney washington state formsouth dakota power of attorney formrental agreement pdf californiaphotography copyright release form templateeforms alabamausaa direct deposit addressblank credit card authorization form templatelandlord notice letter to tenanteviction lettersllc bylaws templaterental agreement mdreal estate hold harmless agreementoperation agreement llc template