My patient has congestive heart failure and Humana. What medications are covered under formulary?
Provider Briefing: Congestive Heart Failure (CHF) Management
Payer: Humana (Medicare Advantage / D-SNP)
Plan Year: 2026
Focus: Clinical Documentation Integrity (CDI) for Formulary Compliance
1. Code & Policy Identification
For CHF, most medications are managed under the Pharmacy Benefit (Part D), but injectable therapies fall under the Medical Benefit (Part B).
| Medication Class | Representative Drugs | CPT/HCPCS Code | Humana Policy / Status |
|---|---|---|---|
| ARNI | Entresto (sacubitril/valsartan) | Oral (Part D) | Preferred (Tier 3); Step Therapy often required. |
| SGLT2 Inhibitors | Farxiga, Jardiance | Oral (Part D) | Preferred; Diagnosis-restricted (HF). |
| sGC Stimulator | Verquvo (vericiguat) | Oral (Part D) | Prior Authorization (PA) Required. |
| IV Iron | Injectafer (ferric carboxymaltose) | J1439 | PA & Step Therapy Required. |
| Inotropic Agents | Milrinone, Dobutamine | J2260 / J1250 | Home infusion requires PA. |
2. Authorization Status
- Standard Therapy (ACEi, ARB, Beta-Blockers): Generally No PA required.
- Advanced Therapy (ARNI/SGLT2i): Typically Step Therapy (must fail ACE/ARB first) rather than a formal PA, though D-SNP plans may vary.
- Verquvo/Corlanor: Prior Authorization Required. Documentation must show a recent HF hospitalization or need for outpatient IV diuretics.
- Injectafer: Step Therapy Required. Humana typically requires a trial of Infed or Venofer before approving Injectafer.
3. The "Documentation Checklist"
To meet Medical Necessity for advanced CHF therapies (Entresto, SGLT2i, Verquvo), the SOAP note must contain these three clinical findings:
- Left Ventricular Ejection Fraction (LVEF): Must document the specific percentage and the date/modality of the last test (e.g., "LVEF 35% via Echo on 01/15/2026").
- NYHA Functional Classification: Clearly state the class (II, III, or IV). Class I (asymptomatic) often leads to denials for advanced branded meds.1
- Evidence of GDMT (Guideline-Directed Medical Therapy): Documentation must show the patient is already on a Beta-Blocker and either an ACE, ARB, or has a documented contraindication.
4. Denial Red Flags
- The "Stable" Trap: If a note describes the patient as "stable" or "doing well" without mentioning persistent NYHA symptoms, Humana may deny a request for Verquvo or Entresto, citing lack of medical necessity for a change in therapy.
- Step Therapy Failure: For Injectafer (J1439), a denial is automatic if the note does not explicitly state: "Patient had an inadequate response or intolerance to oral iron AND a trial of Venofer/Infed."
- Lab Requirements: For SGLT2 inhibitors, ensure the eGFR is documented. Most are contraindicated or require dose adjustment if eGFR <25–30 mL/min/1.73m².1
5. Clinical Action Plan: "Audit-Proof" SmartPhrases
| Scenario | Recommended Documentation Phrase |
|---|---|
| Switching to Entresto | "Patient remains symptomatic (NYHA Class III) despite 90-day trial of maximally tolerated ACE inhibitor (Lisinopril 40mg). Transitioning to ARNI for superior mortality benefit per GDMT." |
| Adding SGLT2i | "Patient with HFrEF (LVEF 30%) and persistent congestion. eGFR is 45 mL/min.1 Adding [Farxiga/Jardiance] to reduce risk of cardiovascular death and HF hospitalization." |
| Ordering IV Iron | "Patient has symptomatic HF with iron deficiency (Ferritin <100 ng/mL or TSAT <20%). Oral iron trial failed due to GI intolerance. Proceeding with IV iron to improve functional capacity." |
Auditor’s Tip: Always link the medication to a specific NYHA Class and LVEF. These two data points are the primary "keys" Humana's automated systems look for during a retrospective audit.
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