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

How to Get Ozempic and Mounjaro Covered by Humana in California: Prior Authorization Forms, Appeal Deadlines, and State Protections

Answer Box: Getting Ozempic/Mounjaro Covered by Humana in California

Humana Medicare Advantage plans in California typically require prior authorization for Ozempic (semaglutide) and Mounjaro (tirzepatide), with both drugs listed as Tier 3-5 specialty medications. Most denials stem from step therapy requirements or lack of diabetes diagnosis documentation. Your fastest path to approval:

  1. Check your 2024 formulary at humana.com/pharmacy/medicare-drug-list
  2. Submit prior authorization with A1c levels, prior medication failures, and diabetes diagnosis
  3. If denied, file redetermination within 65 days using Humana's official appeal form

California residents have additional protections through Independent Medical Review (IMR) if internal appeals fail. Start today by calling the number on your Humana ID card to confirm PA requirements for your specific plan.

Table of Contents

  1. Why California State Rules Matter
  2. Humana's Prior Authorization Requirements
  3. Step Therapy Protections in California
  4. Continuity of Care During Plan Changes
  5. Appeals Process: Internal to External Review
  6. Practical Scripts and Documentation
  7. Understanding ERISA Plan Limitations
  8. Quick Reference Guide

Why California State Rules Matter

California's robust healthcare regulations provide additional protections beyond federal Medicare requirements. While Humana operates under Medicare Part D rules, California's Department of Managed Health Care (DMHC) oversees most HMO and PPO plans, offering Independent Medical Review (IMR) for denials deemed not medically necessary.

Key California advantages:

  • No-cost IMR appeals with 68% approval rates for medical necessity disputes
  • Step therapy override protections (expanding to insulin and diabetes medications in 2026)
  • Continuity of care rights during formulary changes or provider network updates
  • Expedited review timelines for urgent medication needs
Note: Self-funded employer plans (ERISA) may have limited state law protections, but Medicare Advantage plans like Humana are subject to both federal and California regulations.

Humana's Prior Authorization Requirements

Coverage Status and Formulary Placement

Both Ozempic and Mounjaro require prior authorization on most Humana Medicare Advantage plans in California. Check your specific plan's 2024 formulary using Humana's drug list tool, as tier placement affects your copay:

Drug Typical Tier Monthly Cost Range PA Required
Ozempic (semaglutide) Tier 3-4 $47-$150+ after deductible Yes
Mounjaro (tirzepatide) Tier 4-5 $100-$400+ after deductible Yes

Source: Humana Medicare formulary guidelines

Common Approval Criteria

For Type 2 Diabetes:

  • Confirmed diagnosis with ICD-10 code (E11.x)
  • A1c ≥7% despite lifestyle modifications
  • Trial and failure of metformin (unless contraindicated)
  • Documentation of cardiovascular risk factors (for Ozempic's CV indication)

For Weight Management:

  • BMI ≥30 or BMI ≥27 with comorbidities
  • Previous weight loss attempts documented
  • Contraindications to preferred formulary alternatives

Submission Process

  1. Provider completes Humana's coverage determination form
  2. Include required documentation: diagnosis, labs, prior therapies, treatment goals
  3. Submit via provider portal, fax, or mail (verify current contact with plan)
  4. Decision timeline: 72 hours standard, 24 hours expedited

When facing coverage challenges, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements.

Step Therapy Protections in California

Current Rules (2024)

California's step therapy laws currently allow insurers to require trial of preferred medications before covering newer agents like semaglutide or tirzepatide. However, physicians can request step therapy exceptions when:

  • Patient has contraindications to preferred drugs
  • Previous trials resulted in inadequate response or adverse effects
  • Delay would cause significant clinical deterioration

Upcoming Changes (January 2026)

SB 40 will prohibit step therapy for:

  • Insulin products
  • Prescriptive diabetes medications
  • Glucagon

Note: Semaglutide and tirzepatide may still be subject to step therapy requirements, but override provisions will be strengthened.

Documentation for Step Therapy Override

Essential elements for your physician's request:

  • Prior medications tried: drug names, doses, duration, specific reasons for discontinuation
  • Clinical rationale: why the requested medication is medically necessary
  • Patient-specific factors: comorbidities, contraindications, treatment response patterns
  • Timeline urgency: if applicable, why delay poses clinical risks

Source: California step therapy legislation details

Continuity of Care During Plan Changes

When COC Protections Apply

California law mandates continuity of care protections for members with ongoing specialty medication treatments during:

  • Provider network terminations
  • Plan formulary changes
  • Transition between Medicare Advantage plans

Eligibility criteria:

  • Serious or complex medical conditions requiring ongoing treatment
  • Current therapy showing clinical stability or improvement
  • Provider agreement to continue care under previous terms

How to Request COC

  1. Contact Humana within 30 days of receiving termination or formulary change notice
  2. Submit written COC request with medical records documenting treatment necessity
  3. Obtain provider agreement to continue care
  4. Coverage duration: Up to 90 days for transitions, 12 months for ongoing therapy

For formulary changes affecting Ozempic or Mounjaro:

  • Document current treatment stability (A1c improvements, weight loss progress)
  • Note any previous failures with alternative GLP-1 agonists
  • Include prescriber's clinical assessment of switching risks

Source: DMHC Continuity of Care guidelines

Appeals Process: Internal to External Review

Step 1: Humana Internal Appeal (Redetermination)

Timeline: File within 65 days of denial notice Decision: 7 calendar days (72 hours if expedited) Required elements:

  • Completed redetermination form
  • Copy of denial notice
  • Medical necessity documentation
  • Prescriber's clinical rationale

Submit to:

  • Online: resolutions.humana.com
  • Mail: Humana Grievances and Appeals, P.O. Box 14546, Lexington, KY 40512-4546
  • Fax: (verify current number with member services)

Step 2: Independent Review Entity (IRE)

If Humana upholds the denial, your case automatically advances to an Independent Review Entity within 7 days. No additional action required unless you want to submit additional documentation.

Step 3: California Independent Medical Review (IMR)

For HMO/managed care plans regulated by DMHC:

  1. File grievance with Humana first (30-day response required)
  2. Submit IMR application if unsatisfied with grievance outcome
  3. Timeline: 45 days for standard review, 7 days for expedited
  4. Cost: Free to patient
  5. Success rate: 68% approval for medical necessity disputes

Required documentation:

  • Completed IMR form
  • Denial notices and grievance responses
  • Medical records supporting necessity
  • Physician statement citing clinical guidelines

Submit online: dmhc.ca.gov/FileaComplaint Phone assistance: 1-888-466-2219

Source: DMHC Independent Medical Review process

Practical Scripts and Documentation

Phone Script for Humana Member Services

"Hi, I'm calling about prior authorization for [Ozempic/Mounjaro] for my Type 2 diabetes. My member ID is [number]. Can you tell me the specific PA criteria for my plan and provide the submission form? I also need to know if step therapy is required and what documentation my doctor should include."

Medical Necessity Letter Checklist

For clinicians preparing PA requests:

✓ Patient demographics and member ID ✓ Diagnosis with specific ICD-10 codes ✓ Current A1c and BMI with dates ✓ Prior medications tried with doses, duration, and reasons for discontinuation ✓ Clinical rationale citing ADA/AACE guidelines ✓ Contraindications to formulary alternatives ✓ Treatment goals and monitoring plan ✓ Prescriber credentials and contact information

Peer-to-Peer Review Request

"I'm requesting a peer-to-peer review for [patient name] regarding the denial of [medication]. This patient has documented treatment failures with [list medications] and meets clinical criteria per [cite specific guidelines]. When can we schedule the review?"

Understanding ERISA Plan Limitations

Important distinction: While this guide focuses on Medicare Advantage plans subject to California regulations, employer-sponsored plans governed by ERISA have different appeal rights:

  • Limited state law protections (federal law preempts many state requirements)
  • Different appeal timelines and procedures
  • No access to California IMR for ERISA plans

To identify plan type:

  • Check your Summary Plan Description (SPD)
  • Look for ERISA language in plan documents
  • Ask HR or member services directly

Educational note: Always verify your specific plan's regulatory status, as appeal rights vary significantly.

Quick Reference Guide

Key Contacts

Resource Contact Purpose
Humana Member Services Number on ID card PA status, forms, deadlines
DMHC Help Center 1-888-466-2219 IMR assistance, complaints
Humana Appeals resolutions.humana.com Submit redeterminations

Important Deadlines

  • Redetermination: 65 days from denial
  • Expedited appeal: 72 hours if urgent
  • IMR filing: 6 months from plan grievance decision
  • COC request: 30 days from network/formulary change notice

Essential Documents

  • Insurance ID card and policy documents
  • Denial letters and EOBs
  • Complete medical records for the condition
  • Lab results (A1c, lipid panel, kidney function)
  • Documentation of prior medication trials
  • Prescriber's clinical assessment
From our advocates: "We've seen the highest success rates when appeals include specific A1c values, documented weight loss attempts, and clear contraindications to preferred alternatives. Plans respond well to clinical data that directly addresses their published criteria."

Frequently Asked Questions

Q: How long does Humana prior authorization take in California? A: Standard PA decisions are made within 72 hours. Expedited requests for urgent situations are decided within 24 hours.

Q: What if Ozempic or Mounjaro isn't on my formulary? A: You can request a formulary exception with medical necessity documentation. If denied, appeal through the redetermination process and potentially IMR.

Q: Can I request expedited review? A: Yes, if delay in treatment would seriously jeopardize your health. Your physician must document the urgency in the request.

Q: Does step therapy apply if I failed medications in another state? A: Yes, prior treatment failures from any location count toward step therapy requirements. Ensure your new physician has complete records.

Q: What's the difference between Medicare appeals and California IMR? A: Medicare appeals follow federal timelines and processes. California IMR is an additional state-level protection for medical necessity disputes in HMO/managed care plans.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific denial basis and drafts point-by-point rebuttals aligned with each payer's requirements, significantly improving approval rates for complex medications like GLP-1 agonists.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for guidance specific to your situation. For the most current forms and procedures, contact Humana member services or visit official California regulatory websites.

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