Exceptions and appeals

Know the process to ask for a change

If you’re unhappy with some aspect of your coverage or need to make a special request, we want to help. Use these procedures to tell us what’s going on. You can also find detailed information in your plan benefit documents about grievances, appeals, and coverage determinations (including exceptions). A coverage determination is advance approval from Humana to cover a drug.

Exceptions

Do you want your pharmacy plan to cover a prescription in a special way because of your unique circumstances? Ask for a standard decision or coverage determination (the exact term is used in your plan’s contract or Certificate). You, your doctor, or your appointed representative should call Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546), TTY: 711, Monday through Friday, 8 a.m. to 6 p.m. in your local time zone.

If you prefer, you can deliver a written request to:
Humana Clinical Pharmacy Review (HCPR)
ATTN: Coverage Determinations
P.O. Box 33008
Louisville, KY 40232-3008

Grievances

A grievance is a complaint about any aspect of your plan — for example, you have problems with the service you receive, or you believe our notices and other written materials are difficult to understand.

You can file a grievance if your plan fails to provide required notices, give you a decision within the required timeframe, or forward your case to an independent reviewer if you don't receive a decision within the required timeframe. See your plan materials for more details about the timeframe for decisions.

Grievances must be filed within 60 days of when the problem occurred. Please send written grievances to:

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

Or file a verbal grievance by calling the Customer Service phone number on your Humana member ID card.

When calling or writing about a grievance, please have documents that support your request handy (include them with a written grievance) and tell us:

  • Your name
  • Your address
  • Your telephone number
  • Your Humana ID number
  • The reason for the grievance

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

Appeals

If you disagree with our decision to deny payment for an item or service, you can file an appeal. This is a request for us to reconsider our initial decision. Please note that appeals should be written, however, we will accept oral appeals as required by law. See your plan materials for more details about the timeframe for appeals.

You can appeal our decision if you think:

  • We're stopping or reducing coverage for an item or service
  • We won't authorize coverage for an item or service we should cover
  • We haven't paid (or fully paid) a bill we should pay
  • We denied an exception request and you disagree
  • We aren't making a decision within the required timeframe

See your plan materials for details about the time frame for appeals. Generally you can submit your appeal in writing within 60 days of the date of the denial notice you receive. Send it to the address on the Humana Appeals Form. Please include your name, address, Humana ID number, and the reason for the appeal. Also enclose documents that may support your request.

Grievance/Appeal Request Form
(135 KB) English
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Once we receive your appeal, we’ll investigate it and inform you of our decision.

For questions about the appeals process, please call the Customer Service phone number on your Humana member ID card.

Please note that appeals should be written. However, we will accept oral appeals as required by law.

Appoint a representative

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 a signed Appointment of Representative form.

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 instead.

Appointment of Representation Form
(1691 KB) English
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