Coverage Determination Instructions

Standard Coverage Determination for a Medicare Part D Drug

A standard coverage determination about a Medicare Part D drug includes a request about payment for the Medicare Part D drug the member has already received.

Generally, Humana Clinical Pharmacy Review (HCPR) must provide our decision no later than 72 hours after we have received the request, but we will make it sooner if the member's health condition requires. However, if your request involves a formulary exception, a drug placement exception, or an utilization management exception – such as dosage or quantity limits or step therapy requirements – we must make our decision no later than 72 hours after we have received the doctor's supporting statement. This statement explains why the requested drug is medically necessary. Members requesting an exception should submit their prescribing doctor's supporting statement with the request, if possible.

We will provide written notice of our decision under the timeframe explained above. If we do not approve the request, we must explain why and tell the member about his or her right to appeal our decision.

If we have not provided an answer within 72 hours after receiving the request, the request will automatically go to Appeal Level 2, where an independent organization will review the case.

Expedited coverage determination about a Medicare Part D drug the member has not received

If you get an expedited review, HCPR will provide a decision within 24 hours after the member or the member's doctor request an expedited review – sooner if the member's health condition requires. If the request involves a request for an exception, we must make our decision no later than 24 hours after we get the doctor's supporting statement, which explains why the requested non-formulary or non-preferred drug is medically necessary. We will provide written notice of our decision under the timeframe explained above. If we do not approve the request, we must explain why and tell the member about his or her right to appeal our decision.

If we decide the request is eligible for an expedited review and we have provided a response within 24 hours after receiving the request, the request will automatically go to Appeal Level 2, where an independent organization will review the case.

If we do not grant the member's or doctor's request for an expedited review, we will provide a decision within the standard 72-hour timeframe discussed above. If we contact you by phone, we will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a grievance. We will automatically give the member an expedited decision if he or she gets a doctor's support for an expedited review.

Instructions for completing a coverage determination request form:

1. The patient and/or their provider must fill out the Request for Medicare Prescription Drug Coverage Determination Form in its entirety.
2. The form should be either mailed to:

Humana Clinical Pharmacy Review
1951 Bishop Lane
Suite 500
Louisville, KY 40218

It may be faxed to: 1-877-486-2621.

You may also phone in the request by calling HCPR at 1-800-555-CLIN (2546) between the hours of 8 a.m. and 9 p.m., Eastern time, Monday through Friday.

Download & Print

Provider Request for Coverage Determination Form
89.9KB - Download PDF

Member Request for Coverage Determination Form
1.6MB - Download PDF