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), TTY: 711, Monday – Friday, 8 a.m. – 6 p.m. in your local time zone. If you prefer, you can deliver a written request to:

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

Member request for Coverage Determination Form

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Note: You can also access the Request for Coverage Determination Form at the CMS Part D appeals webpage link below:

Part D Request for Medicare Prescription Drug Determination Request Form (for use by enrollees)

Grievances

A grievance is a complaint about any aspect of your plan.

What types of problems may lead to a grievance?

• You feel that you're being encouraged to leave (disenroll from) Humana
• Problems with the service you receive
• Problems with how long you have to wait on the phone or in the pharmacy
• Disrespectful or rude behavior by pharmacists or other staff
• Cleanliness or condition of pharmacy
• If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination
• You believe our notices and other written materials are difficult to understand
• Failure to give you a decision within the required timeframe
• Failure to forward your case to the independent review entity if we don't give you a decision within the required timeframe
• Failure by us to provide required notices
• Failure to provide required notices that comply with CMS standards

Grievances must be filed within 60 days of occurrence. Direct your written grievance to:

Humana Grievances and Appeals
P.O. Box 14165
Lexington, KY 40512-4165
Fax: 1-800-949-2961

You can file a verbal grievance by calling:
1-800-457-4708
TTY: 711
Hours:
8 a.m. to 8 p.m. Eastern time, Monday through Friday
8 a.m. to 8 p.m. Eastern time, Saturday and Sunday (available October 15 – February 14 only)

Please include:

• Your name
• Your address
• Your telephone number
• Your Humana ID number
• The reason for the grievance in your letter
• Documents that support your request

We'll investigate your grievance and inform you of our decision.

Appeals

If you disagree with our decision to deny payment for a prescription drug, you can file an appeal. This is a request for us to reconsider our initial decision.

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

• We're stopping or reducing coverage for a drug
• We won't authorize coverage for a drug we should cover
• We haven't paid a bill we should pay
• We haven't paid a bill in full that we should have paid in full
• We denied an exception request and you disagree
• We aren't making a decision within the required time frame

You must submit you appeal in writing within 60 calendar days of the date of the denial notice you receive from us. Send it to the address on the Humana Appeals Form.

Medicare Members

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For questions about the appeals process, please call:
1-800-457-4708
TTY: 711
Hours:
8 a.m. to 8 p.m. Eastern time, Monday through Friday
8 a.m. to 8 p.m. Eastern time, Saturday and Sunday (available October 15 – February 14 only)

Please note that appeals should be written. We'll accept oral appeals if you're unable to write an appeal.

Please include:

• Your name
• Your address
• Your Humana ID number
• The reason for the appeal
• Documents that may support your request

We'll investigate your appeal and inform you of our decision.

You can also find detailed information in your Evidence of Coverage (EOC) with regards to grievances, coverage determinations (including exceptions), and the appeals process.

Instructions for Submitting a Request for Reconsideration to the IRE

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

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

To request a reconsideration – you should submit your request to MAXIMUS at the address or fax number 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: 585-425-5301

Your doctor has the right to file a standard reconsideration (appeal) pre-service request on behalf of the member as long as you're notified. An Appointment of Representative (AOR) form isn't required.

For prescription drug plans, your prescribers have the right to file a standard redetermination request on your behalf as long as you're notified. An AOR form isn't required.

Instructions about How to Appoint a Representative

Appointment of Representation Form

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You also can get the Appointment of Representative form on CMS's website.

To consider a request from someone other than you, we must have a valid authorization. You can appoint anyone 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 also can file a request on your behalf after sending us the appropriate legal representative document. You don't need to complete an Appointment of Representative Form if you provide a valid legal representation document with your request.

About Prior Authorization

Some drugs on Humana's Drug List – also called a "formulary" – need a prior authorization. If your drug needs prior authorization, your prescription may not be covered unless your doctor requests and receives approval from Humana.

For drugs that require prior authorization, the doctor must contact Humana in one of two ways:

1. Phone in the request by calling HCPR at 1-800-555-CLIN (2546), TTY: 711, between 8 a.m. and 6 p.m. in your local time zone, Monday through Friday.
2. Complete the form in its entirety and include a supporting statement of medical necessity. The supporting statement may include specific patient medical information as well as peer-reviewed literature related to the request if applicable.

Mail the form to:

Humana Clinical Pharmacy Review
P.O. Box 33008
Louisville, KY 40232-3008

The form can be faxed to 1-877-486-2621.

Prior Authorization Fax Form

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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.