Humana
Medicare-focused (no employer commercial book) · updated August 8, 2026
Coverage right now
- Foundayo™ (orforglipron) Excluded
- Saxenda® (liraglutide) Excluded
- Wegovy® (semaglutide injection) Excluded
- Zepbound® (tirzepatide) Excluded
Humana exited employer-group commercial medical (completed ~2024) — treat 'Humana commercial' as N/A; several consumer sites erroneously describe active plans. Its Part D formularies exclude weight-loss GLP-1s (statute), covering CV/MASH/OSA indications with PA on some formularies. Unusual dual role: Humana is CMS's central processor for the Medicare GLP-1 Bridge (BIN 028918, PCN MEDDGLP1BR), adjudicating $50 Bridge claims for all Medicare beneficiaries nationwide.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Zepbound® (tirzepatide) | Excluded | Part D weight-loss exclusion; OSA-indication coverage possible with PA on some formularies. KwikPen covered under the Bridge from 7/1/2026. source | medium |
| Wegovy® (semaglutide injection) | Excluded | Part D weight-loss exclusion; CV-risk-reduction indication coverable with PA (plan attests not-for-weight-loss). All formulations covered under the Bridge. source | medium |
| Foundayo™ (orforglipron) | Excluded from Jul 1, 2026 | Not Part D-covered for weight loss; fully covered under the Bridge at $50/month. source | high |
| Saxenda® (liraglutide) | Excluded | Not in the Bridge; Part D exclusion applies. source | high |
What preferred, covered and exception only mean
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.
Prior authorization criteria
medium- PA required
- Yes for indication-based Part D coverage (CV/MASH/OSA) — the plan verifies the drug is NOT for weight loss. The Bridge replaces plan PA with prescriber attestation to a BMI category.
- Initial BMI
- Bridge categories: BMI >= 35 (no comorbidity needed); BMI >= 30 with HFpEF, uncontrolled hypertension, or CKD >= 3a; BMI >= 27 with pre-diabetes, prior MI, stroke, or symptomatic PAD.
- Comorbidities
- Per Bridge categories; Humana PA also screens MTC/MEN2 history.
- Lifestyle requirement
- Bridge: attestation of 'current and ongoing lifestyle modification' — no program documentation required.
- Initial authorization
- Bridge PAs valid through Dec 31, 2027. Humana indication-based PAs: not published (secondary: 6-12 months).
- Reauthorization
- Not applicable to CV/OSA indication coverage.
- Step therapy
- None documented for CV-indication Wegovy.
- Quantity limits
- Not published in retrieved documents.
Primary criteria document:cms.gov
Exceptions and appeals
- Appeal deadline
- 65 days
- Deadline detail
- 65 calendar days from the coverage-determination notice (changed from 60 on Jan 1, 2026 — most guides are stale).
- Exception route
- Part D coverage determination via Humana Clinical Pharmacy Review 1-800-555-2546 or CoverMyMeds. Bridge claims bypass the plan entirely.
- Turnaround
- Part D coverage determination: 72h standard / 24h expedited. Redetermination decision: 7 days standard / 72h expedited.
- Where
- Per your Humana denial letter.
Source:cms.gov
Dated changes
If you have Humana Part D and want a GLP-1 for weight loss: the Bridge is the route, not a plan appeal. If you have T2D, OSA, or MASH, standard Part D with the indication-based PA is the route instead.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.