Please note the following regarding Medically Accepted Indications
All reasonable efforts have been made to ensure consideration of medically accepted indications in this policy. Medically accepted indications are defined by CMS as those uses of a covered Part D drug that are approved under the federal Food, Drug, and Cosmetic Act, or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in section 1927(g)(1)(B)(i) of the Act. These compendia guide review of off-label and off-evidence prescribing and are subject to minimum evidence standards for each compendium. Currently, this review includes the following references when applicable and may be subject to change per CMS:
- American Hospital Formulary Service (AHFS) Compendium
- Thomson Micromedex/DrugDex (not Drug Points) Compendium
- National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium™
- Elsevier Gold Standard's Clinical Pharmacology Compendium
Request Submission
Doctors can submit their requests to Humana Clinical Pharmacy Review (HCPR) through the following methods.
Phone & Fax Requests
Hours: 8:00 a.m. to 9:00 p.m. EST Monday through Friday
Phone Requests: 1-800-555-CLIN (2546)
Fax Requests: Complete the applicable form below and fax to 1-877-486-2621
Coverage Determination Forms
- Request for Coverage Determination
- (0.5 MB) Download PDF
- English | Spanish
If you prefer, you may complete the form online. Before completing the form, you may want to view our accepted file types.
Coverage Determination Request Form
Another option is to use the Coverage Determination Request Form on the CMS website.
Note: These documents are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to Download Adobe Reader