Pharmacy, prescription, and medication benefits and information
Humana works with you and your doctor to make sure you get the medicine you need. The Prescription Drug Guide includes information about the medicine Humana Gold Plus Integrated plan covers.
You sometimes have to pay for your prescriptions. Some prescription drugs have limits.
Why do some drugs have limits?
For certain prescription drugs, special rules limit how and when we cover them. In general, our rules encourage you to get a drug that is safe and effective and that works for your medical condition. When a safe, lower-cost drug will work just as well as a high-cost drug, the plan expects your provider to use the lower-cost drug.
Getting approval in advance
For some drugs, you or your doctor must get approval from Humana Gold Plus Integrated, before you fill your prescription. This approval is called prior authorization. If you do not get approval, Humana Gold Plus Integrated plan may not cover the cost of the drug.
How do I know if a drug requires prior authorization?
- Have your doctor call the Customer Care number on the back of your Humana member ID card
- To ask for a prior authorization, please have your doctor fill out the 2020 Prior Authorization Request Form (PDF opens in new window)
- Have your doctor go online and start a prior authorization request (link opens in new window).
Request a Coverage Determination or Fast Coverage Determination
A coverage determination (sometimes called "coverage decision") is an initial decision we make about your benefits and coverage, or about how much we will pay for your healthcare services, items, or medicine. We make a coverage decision each time we decide what is covered for you and how much we pay.
To request a coverage determination, please complete the CMS Model Coverage Determination Request form (pdf opens in new window).
You can return the form to us by fax or in the mail:
Fax number: 1-877-486-2621
Humana Clinical Pharmacy Review (HCPR)
P.O. Box 33008
Louisville, KY 40232-3008
Prior Authorization and Step-Therapy Criteria
- Illinois Prior Authorization Criteria
- Illinois Step-Therapy Criteria
Mail-order pharmacy services
For certain kinds of drugs, you can fill prescriptions through our mail-order Humana Pharmacy. Generally, the drugs available through mail-order are drugs that you take on a regular basis for a chronic or long-term medical condition. The drugs available through our plan’s mail-order service are marked as mail-order drugs in our Preferred Drug List. Our plan’s mail-order service allows you to order up to a 90-day supply of your prescription drugs sent directly to your home.
To get order forms and information about filling your prescriptions by mail, call Customer Service at 1-800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time. However, please note that our automated phone system may answer your call after-hours, during weekends, and on holidays. Please leave your name and telephone number, and we’ll call you back by the end of the next business day.
Over-the-counter supplemental benefit
You are eligible to get up to $30 each quarter to use toward the purchase of over-the-counter (OTC) health and wellness products available through our mail-order Humana Pharmacy.
To get an order form:
- Call Customer Care at 1-800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time
- Complete and send us the OTC Order Form
What is Medication Therapy Management Program?
Medication Therapy Management (MTM), while not a part of a prescription drug benefit, is a Medicare-designed program sponsored by Humana’s RxMentor program. If you’re taking multiple medicines prescribed by more than one doctor, these medicines, when combined, may:
- Cause severe side effects
- Cost you more money per month
- Reduce their efficacy
As part of your Part D coverage with Humana, you can set up a one-on-one Comprehensive Medication Review (CMR) of your medicines with a pharmacist. This review is free.
Once enrolled in the program, you’ll stay up to date through monthly mailings. Some of our members even qualify for face-to-face or over-the-phone help.
Best Available Evidence (BAE) policy
These are rules that specify the requirements of Part D plans in the administration of the low-income subsidy (LIS) program, including the lowering of costs for subsidy-eligible individuals. In certain cases, CMS systems do not always reflect a beneficiary’s correct low-income subsidy status, also known as “extra help.” As a result, the plan does not have the subsidy-eligible individual’s right subsidy information.
To help with the situation, CMS created the Best Available Evidence (BAE) policy (link opens in new window) . This policy requires sponsors (health plans) to correct the cost-sharing for beneficiaries who meet income requirements, when presented with proof that the on-hand information is not right.
Quality Assurance Policy and Procedures
Humana wants its members to get safe, high-quality, and affordable medication. Several policies and procedures make sure this happens.
The Concurrent (49 KB) (PDF opens in new window) & Retrospective Drug Utilization Review (DUR) program (53 KB) (PDF opens in new window) helps make sure prescriptions are appropriate, medically necessary, and unlikely to have bad medical results.
Pharmacy Claim Form
Prescription Drug Claim Form for Member Reimbursement
Illinois residents that have Medicaid and Medicare can get their benefits from the same place.