Prescription drug exceptions and appeals

Find out how to request coverage for a prescription drug.

Medicare exceptions and appeals

You have a voice. Speak up if you think a certain drug should be covered, or just have questions about the service you receive. Here's how to do it.

Exceptions

If a drug is not currently covered under Medicare, find out whether it could be. Request a coverage determination for a prescription drug.

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, deliver a written request to:

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

Access a Request for Coverage Determination form as a PDF, or online via the Part D appeals webpage.

Member Request for Coverage Determination Form
Download PDF (89.9KB)

Online Part D Request for Medicare Prescription Drug Determination Request Form

Grievances

A grievance is a complaint that you may have about any aspect of your plan. You may have a grievance if you:

  • Feel you're being encouraged to leave (disenroll from) Humana
  • Experience problems with the service you receive, including too-long wait times, or disrespectful or rude behavior by pharmacists or other staff
  • Have concerns about the cleanliness or condition of pharmacy
  • Disagree with our decision not to expedite your request for an expedited coverage determination or redetermination
  • Fail to understand our notices and other written materials
  • Do not receive a decision within the required timeframe
  • Do not have your case forwarded to the independent review entity if we don't give you a decision within the required timeframe
  • Do not receive required notices, or do not receive required notices that comply with CMS standards

Grievances must be filed within 60 days of the 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,
Monday – Friday, 8 a.m. – 8 p.m. Eastern time or
Saturday and Sunday, 8 a.m. – 8 p.m. Eastern time (available October 15 – February 14 only)

Please include your name, address, telephone number, Humana ID number, the reason for your grievance, and any supporting documents. We'll investigate your grievance and inform you of our decision.

Appeals

If you disagree with a decision to deny payment for a prescription drug, you can file a request for Humana to reconsider. You have the right to appeal a decision if:

  • You think Humana is stopping or reducing coverage for a drug
  • You have not received authorized coverage for a drug Humana should cover
  • A bill has not been paid or paid in full
  • You disagree with a denied exception request
  • You did not receive 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.

Grievance/Appeal Request Form
Download PDF (42 KB)

Include your name, address, Humana ID number, reason for the appeal, and any supporting documents. We'll investigate your appeal and inform you of our decision. If you're unable to write an appeal, oral appeals will be accepted.

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

Request for reconsideration

If you have already appealed and the original decision still stands, there are further steps you can take. Request an independent review and determination of the case by the Center for Health Dispute Resolution (MAXIMUS). MAXIMUS is the Centers for Medicare & Medicaid Services (CMS) contractor.

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

Members of a Part D Prescription Drug Plan or Medicare Advantage Prescription Drug Plan should contact:

MAXIMUS Federal Services
860 Cross Keys Park
Fairport, NY 14450
Fax: 585–425–5301

You can appoint another person to submit a request, but you must have valid authorization. Have an Appointment of Representative (AOR) form signed by both you and the representative. If you have a representative who is appointed by the court or who is acting in accordance with state law, an AOR form is not required. Instead, provide a valid legal representation document with your request.

Your doctor has the right to file a standard reconsideration (appeal) pre–service request on your behalf 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.

Appointment of Representation Form
Download PDF (1691 KB)

Appointment of Representative Form via CMS's website

Prior authorization

Some drugs on Humana's Drug List (or "formulary") need advance approval for the prescription to be covered. This is known as prior authorization.

For drugs that require prior authorization, your 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. – 6 p.m. in your local time zone, Monday – 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 any applicable peer–reviewed literature.

Mail prior authorization forms to:
Humana Clinical Pharmacy Review
P.O. Box 33008
Louisville, KY 40232–3008 Or
fax to: 1–877–486–2621

Prior Authorization fax form
Download PDF (34KB)

Contact Humana with questions

Medicare Advantage Prescription Drug Plan members who have questions can call 1–800–457–4708, TTY: 711, Prescription Drug Plan–only members can call 1–800–281–6918, TTY: 711, Monday – Friday, 8 a.m. – 8 p.m. Eastern time.

If your doctors have questions or needs information about the grievance, appeals, or exceptions process, refer them to the Customer Service number on the back of your member ID card.