The Clinical Policy and Pharmacy & Therapeutics areas of Humana are responsible for developing policies regarding services (devices, procedures, medications) using evidence-based medicine.

Humana develops Medicare Advantage (MA) coverage policies when the Centers for Medicare & Medicaid Services guidance for a service or indication for a service is not fully established.

Creation of these policies involve clinicians conducting reviews of current evidence in widely used treatment guidelines or clinical literature, including, but not limited to:

• Medicare national coverage determinations (NCDs), local coverage determinations (LCDs) and other Original Medicare guidance
• Milliman Care Guidelines (MCG©)
• Peer-reviewed medical journals
• The National Library of Medicine
• Specialty organizations, national treatment guidelines and AMCP dossier
• Medical research web sites
• Medical textbooks

The policies are presented to the applicable committees:

• Utilization Management Committee (UMC)
• Pharmacy &Therapeutics (P&T) Committee
• Technology Assessment Forum (TAF)—for acceptance or modification

The committees include physicians and other clinicians in alignment with applicable requirements.

The medical and pharmacy coverage policies help ensure consistent medical review while continuing to take into account individual considerations.

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