By Counterforce Health Team in Ozempic / Mounjaro (semaglutide / tirzepatide) —

Getting Ozempic and Mounjaro Covered by Humana in Virginia: Prior Authorization, Appeals, and Step-by-Step Guide

Quick Answer: Getting Humana to Cover Ozempic or Mounjaro in Virginia

Yes, Humana covers Ozempic and Mounjaro for type 2 diabetes, but requires prior authorization and step therapy (trying metformin first). Your fastest path: 1) Have your doctor document failed metformin trial and current A1c >7%, 2) Submit PA through Humana provider portal, 3) If denied, file internal appeal within 60 days. Virginia residents get external review through the State Corporation Commission if internal appeals fail. Start today by checking your formulary at Humana.com and gathering your diabetes treatment history.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Formulary Status: Where Ozempic and Mounjaro Rank
  3. Prior Authorization & Step Therapy Requirements
  4. Specialty Pharmacy Network & Prescription Routing
  5. Understanding Your Costs
  6. Submission Process: Forms and Documentation
  7. Appeals Process in Virginia
  8. Common Denial Reasons & Solutions
  9. When to Contact Virginia Regulators
  10. FAQ

Humana Plan Types & Coverage Implications

Humana offers several plan types in Virginia, each with different coverage rules for Ozempic (semaglutide) and Mounjaro (tirzepatide):

Medicare Advantage Plans: Most common Humana coverage in Virginia. These plans cover diabetes medications under Part D pharmacy benefits, but not for weight loss—only for type 2 diabetes with documented medical necessity.

Employer Group Plans: Coverage varies by employer contract. Some may include weight management benefits that traditional Medicare excludes.

Medicaid Plans: Limited Humana Medicaid presence in Virginia, but when available, typically requires extensive prior authorization for newer diabetes medications.

Note: All Humana plans require you to use in-network pharmacies or pay significantly higher costs. Emergency situations may provide temporary out-of-network coverage.

Formulary Status: Where Ozempic and Mounjaro Rank

Both medications appear on most Humana formularies but at different tiers:

Medication Typical Tier Monthly Cost Range* Alternatives
Ozempic (semaglutide) Tier 3-4 $25-$150 copay Trulicity, Victoza
Mounjaro (tirzepatide) Tier 3-4 $25-$150 copay Ozempic, Rybelsus

*Costs vary by specific plan and deductible status

Key Finding: According to Humana's 2025 formulary documents, both medications require prior authorization across most plans, with step therapy requirements for first-line agents like metformin.

Check your specific formulary at Humana's drug list tool or call member services for current tier placement.

Prior Authorization & Step Therapy Requirements

Medical Necessity Criteria

Humana requires documentation of:

  • Confirmed type 2 diabetes diagnosis with ICD-10 code
  • Current A1c level ≥7% despite other therapies
  • Failed trial of metformin (unless contraindicated)
  • Clinical rationale for choosing GLP-1 therapy

Step Therapy Process

Before approving Ozempic or Mounjaro, Humana typically requires:

  1. First-line: Metformin (regular or extended-release)
  2. Second-line: Additional oral agents (sulfonylureas, SGLT2 inhibitors)
  3. Third-line: GLP-1 receptor agonists like Ozempic or Mounjaro

Exception: Patients already on these medications with paid claims in the past year may be exempt from step therapy requirements.

Required Documentation

Your healthcare provider must submit:

  • Recent A1c results and trends
  • Complete medication history with dosages and outcomes
  • Documentation of side effects or contraindications to preferred agents
  • Treatment goals and monitoring plan

Specialty Pharmacy Network & Prescription Routing

Primary Fulfillment Channel

CenterWell Specialty Pharmacy is Humana's owned specialty pharmacy and preferred fulfillment channel for Ozempic and Mounjaro. Benefits include:

  • Direct coordination with Humana for prior authorization
  • Patient support services and injection training
  • 30-day supply limits (standard for specialty medications)
  • Mail delivery to your preferred address

Contact: 1-800-486-2668 for new prescriptions or transfers

Network Alternatives

While CVS Specialty and Accredo may be in-network for some Humana plans, verify coverage before transferring prescriptions. Using out-of-network specialty pharmacies can result in:

  • Higher copays or full cash payment
  • Denied claims requiring appeals
  • Loss of manufacturer copay card benefits
Tip: Always confirm pharmacy network status through your MyHumana account or by calling member services before filling specialty medications.

Understanding Your Costs

Typical Cost Structure

  • Deductible: May apply before copay kicks in (varies by plan)
  • Copay/Coinsurance: $25-$150 monthly for tier 3-4 medications
  • Out-of-pocket maximum: Provides annual cost protection

Manufacturer Support Programs

  • Ozempic: Novo Nordisk offers savings cards for eligible patients
  • Mounjaro: Eli Lilly provides cost assistance programs

Note: Medicare patients typically cannot use manufacturer coupons, but some employer plans allow them.

Submission Process: Forms and Documentation

For Healthcare Providers

Prior Authorization Submission:

  1. Access Humana provider portal or fax forms to designated PA line
  2. Include complete clinical documentation package
  3. Submit within required timeframes (typically 72 hours for standard review)

Required Elements:

  • Patient demographics and insurance information
  • Diagnosis codes (ICD-10)
  • Current and previous medications with outcomes
  • Laboratory results (A1c, eGFR, etc.)
  • Clinical notes supporting medical necessity

For Patients

Gathering Documentation:

  • Insurance card and member ID
  • Complete list of diabetes medications tried
  • Recent lab results
  • Any denial letters or previous appeals

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals aligned with the plan's own rules.

Appeals Process in Virginia

Internal Appeals (Humana)

Timeline: 60 days from denial notice Process: Submit appeal through member portal, mail, or phone Documentation: Include new clinical information not in original request

External Review (Virginia SCC)

If Humana's internal appeal fails, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance:

Deadline: 120 days from final internal denial Forms Required: Form 216-A (External Review Request) Submission:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: SCC Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (with physician certification)
Virginia Advantage: The state's external review process has helped many patients overturn wrongful denials, with independent medical experts reviewing cases.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Not medically necessary" Provide current A1c ≥7% and failed alternatives Lab results, medication history
"Step therapy not met" Document metformin trial/contraindication Prescription records, side effect notes
"Non-formulary" Request formulary exception Clinical justification letter
"Quantity limits exceeded" Justify dosing based on FDA labeling Prescriber attestation

Medical Necessity Letter Template

Healthcare providers should include:

  1. Patient background: Age, diabetes duration, complications
  2. Treatment history: Specific agents tried, dosages, outcomes
  3. Clinical rationale: Why GLP-1 therapy is appropriate
  4. Monitoring plan: Follow-up schedule and goals
  5. Supporting guidelines: Reference ADA/AACE standards

When to Contact Virginia Regulators

Contact the Virginia State Corporation Commission Bureau of Insurance if:

  • Humana fails to respond to appeals within required timeframes
  • You believe coverage was wrongfully denied
  • You need guidance on the external review process

Contact Information:

  • Phone: 1-877-310-6560
  • Consumer Services available for informal resolution attempts
  • Free external review process (no fees charged)

The Bureau's Managed Care Ombudsman can also assist with understanding appeal rights and may help resolve issues informally before formal external review.

FAQ

How long does Humana prior authorization take in Virginia? Standard reviews: 72 hours. Expedited reviews (when delay could cause harm): 24 hours. Virginia law requires prompt compliance with approved authorizations.

What if Ozempic or Mounjaro isn't on my formulary? Request a formulary exception with clinical documentation. Humana must provide written response within required timeframes and explain denial reasons.

Can I request expedited appeal if I'm already taking the medication? Yes, if discontinuation could seriously harm your health. Your physician must certify the urgency in writing.

Does step therapy apply if I tried metformin in another state? Yes, medication history from any provider counts toward step therapy requirements. Ensure your Virginia provider has complete records.

What's the difference between internal and external appeals? Internal appeals are reviewed by Humana; external appeals in Virginia are reviewed by independent medical experts through the State Corporation Commission.

Can I use manufacturer copay cards with Humana? Depends on your plan type. Medicare Advantage patients typically cannot use manufacturer coupons, but some employer plans allow them.

From our advocates: We've seen patients succeed by working closely with their healthcare providers to document the complete story—not just current A1c, but the progression over time, side effects from previous medications, and specific clinical goals. The key is painting a clear picture of medical necessity that aligns with Humana's own criteria.

When navigating Humana's coverage requirements becomes complex, Counterforce Health helps patients and clinicians turn denials into successful appeals by identifying the specific denial basis and crafting evidence-backed responses that meet payer requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and review your plan documents for the most current information. For personalized guidance on Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance.

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