Prescription Drug Exceptions and Appeals

Exceptions

To ask for a standard decision, you, your doctor, or your appointed representative should call Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546), or you can deliver a written request to:

Humana Clinical Pharmacy Review (HCPR)
ATTN: Medicare Coverage Determinations
P.O. Box 33008
Louisville, KY 40232-3008

You may also fax it to 1-877-486-2621.

Provider request for Coverage Determination

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Puerto Rico HCPR
Humana Health PLans of Puerto Rico, Inc.
PO Box 191920
San Juan, PR 00919-1920
Phone: 1-866-488-5991
Fax: 1-866-423-0486

If you would prefer, you can complete the form online. Before completing the form, you may want to view our accepted file types.

Coverage Determination Request Form

Part D Coverage Redetermination Requests

Prescribers who do not agree with the outcome of the initial coverage determination may appeal the decision by requesting a standard or expedited coverage redetermination. If the request for coverage of (or payment for) a prescription drug has been denied, you have the right to ask us for a redetermination (appeal) of our decision. Within 60 calendar days of the date of the denial notice you received from us, you may do the following:

Request an Expedited Coverage Redetermination

If you believe that waiting seven days for a standard decision could seriously harm the patient's life, health or ability to regain maximum function, you can ask for an expedited (fast) decision and we will automatically give you a decision within 72 hours. You may request an expedited decision by calling us at 1-800-867-6601, or by faxing us at 1-800-949-2961.

Request a Standard Part D Coverage Redetermination Online

Follow these directions to use our online standard coverage redetermination form:

1. Enter the prescription drug information.
2. Indicate the reason you are appealing the denial.
3. Provide any clinical rationale.
4. Enter your information.
5. Attach supporting documentation for your appeal.

Coverage Redetermination Request Form

Before completing the form, you may want to view our accepted file types.

If you need to fax supporting documentation, please fax the materials to 1-877-486-2621.

Once Humana receives your request, we will provide written notice of our decision within seven calendar days.

Request a Standard Part D Coverage Redetermination by Phone

You may file a standard verbal redetermination request by calling us toll free at 1-800-457-4708. If you use a TTY, call 711. Our hours are from 8 a.m. to 8 p.m. local time, Monday through Friday. Extended coverage from October 15 to February 14 will be available on Saturdays and Sundays from 8 a.m. to 8 p.m.

We strongly encourage prescribers to provide additional supporting documentation for appeals.

Once the request is received, Humana will provide written notice of our decision within seven calendar days for standard requests.

Grievances

A grievance is a complaint expressing dissatisfaction with any aspect of the plan.

What types of problems might lead to you filing a grievance?

• You feel that you are being encouraged to leave (disenroll from) Humana;
• Problems with the Member Service you receive;
• Problems with how long you have to spend waiting on the phone or in the pharmacy;
• Disrespectful or rude behavior by pharmacists or other staff;
• If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination;
• Failure to give you a decision within the required timeframe;
• Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe;
• Failure by us to provide required notices; or
• Failure to provide required notices that comply with CMS standards.

Grievances must be filed within 60 days of occurrence.

Direct your written grievance to the following address:

Humana Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4165
Fax # 1-800-949-2961

Include your name, address, telephone number, Humana ID number and the reason for the grievance in your letter. Please include any supporting notes or documents that may support your request. We will investigate your grievance and inform you of our decision.

Appeals

If you disagree with our decision to deny payment of a claim or coverage for a prescription drug, you may file an appeal to request that we reconsider our initial decision.

You have the right to appeal our decision if you think the following:

• We are stopping or reducing coverage for a drug.
• We will not authorize coverage for a drug we should cover.
• We have not paid a bill we should pay.
• We have not paid a bill in full that we should have paid in full.
• We have denied an exception request and you disagree; or
• We are not making a decision within the required time frame.

Within 60 calendar days of the date of the denial notice you received from us, submit your appeal in writing to the following address:

Humana Appeals
P.O. Box 14546
Lexington, KY 40512-4546
Fax: 1-800-949-2961
For questions regarding the appeals process, please call:
1-800-457-4708 or TDD# 1-800-833-3301 (hearing impaired).

Please note that appeals should be written but oral appeals will be accepted for reasons of illiteracy, handicap, or illness.

Include your name, address, Humana ID number and the reason for the appeal in your letter. Please include any supporting notes or documents that may support your request. We will investigate your appeal and inform you of our decision.

Instructions for Submitting a Request for Reconsideration to the IRE

If you disagree with our decision to maintain the denial, you may request a review of the case by the Center for Health Dispute Resolution (MAXIMUS), the Centers for Medicare & Medicaid Services (CMS) contractor, for an independent review and determination.

You must submit a written request to MAXIMUS within 60 calendar days of our decision. You may request either a standard appeal (reconsideration) or an expedited appeal (fast reconsideration) from the independent review organization.

To request a reconsideration, you should submit your request to MAXIMUS at the address or fax number listed below:

For members of a Part D Prescription Drug Plan or Medicare Advantage Prescription Drug Plan:

MAXIMUS Federal Services 860 Cross Keys Park
Fairport, NY 14450
Fax # 1-585-425-5301

The member's treating physician has the right to file a standard reconsideration (appeal) pre-service request on behalf of the member as long as the member is notified. An AOR is not required.

For Prescription Drug Plans, the member's prescribing physicians and other prescribers have the right to file a standard redetermination request on behalf of the member as long as the member is notified. An AOR is not required.

Instructions about How to Appoint a Representative

Appointment of Representation Form

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To consider a request from someone other than the member, we must have authorization. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

About Step Therapy

With step therapy drugs, Humana requests that you try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Humana may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Humana will cover Drug B.