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Pharmacy

The Humana Gold Plus® Integrated Medicare-Medicaid plan includes coverage for prescription medicine. We work with you and your doctor to make sure you get the medicine you need.

Pharmacist prepares a prescription

Medication benefits and information

Humana Gold Plus Integrated members have a $0 pharmacy copayment. Certain prescription medicines have special rules that may limit how and when we cover them. In general, these rules encourage you to use a medicine that is safe, effective, and works for your medical condition.

However, if a safe, lower-cost medicine will work just as well as a medicine that costs more, we expect your provider to prescribe you the medicine that costs less. This process is called step therapy.

2021 Illinois Step-Therapy Criteria, PDF opens new window

2022 Illinois Step-Therapy Criteria, PDF opens new window

For information about the medicine Humana Gold Plus Integrated covers, refer to the Prescription Drug Guide.

2021 Prescription Drug Guide – English, PDF opens new window

2021 Prescription Drug Guide – Spanish, PDF opens new window

2022 Prescription Drug Guide – English, PDF opens new window

2022 Prescription Drug Guide – Spanish, PDF opens new window

Getting approval in advance

For some medicine, 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, the Humana Gold Plus Integrated plan may not cover the cost of the drug.

To find out if a medicine needs prior authorization, your doctor can:

  • Call the Customer Care phone number on the back of your Humana member ID card
  • Start an online prior authorization request
  • Submit a Prior Authorization Request Form

2021 Illinois Prior Authorization Criteria, PDF opens new window

2022 Illinois Prior Authorization Criteria, PDF opens new window

Request a coverage determination

A coverage determination (sometimes called "coverage decision") is an initial decision we make about:

  • Your benefits and coverage
  • 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.

Procedures for filing a coverage determination

To request a coverage determination, please:

Mail-order pharmacy services

For certain kinds of medicine, you can fill prescriptions through our mail-order Humana Pharmacy®. Generally, the medicine available through mail order is medicine you take on a regular basis for a chronic or long-term medical condition. We mark medicine available through our plan’s mail-order service in our Prescription Drug Guide as “mail-order drugs.” 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 Care at 800-379-0092 (TTY: 711), Monday – Friday, 8 a.m. – 11 p.m., and Saturday, 8 a.m. to 6:30 p.m., Eastern 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

In 2021, members 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. In 2022, members are eligible to get up to $65 each quarter.

To get an order form:

  • Complete and send us the OTC Order Form

OTC Catalog and Order Form – English, PDF opens new window

OTC Catalog and Order Form – Spanish, PDF opens new window

  • Call Customer Care at 800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time

Medication Therapy Management

Medication Therapy Management (MTM), while not part of a prescription drug benefit, is a Medicare-designed program sponsored by Humana.

Learn more about our MTM program

Prescription medicine transition policy and guidelines

Humana has established a process to:

  • Address the needs of individuals who are joining our plan from other providers
  • Ensure a smooth transition process for our members

View our prescription medicine transition policy and guidelines , PDF opens new window

Reimbursement for pharmacy expenses

Our members have a $0 copayment on prescription medicine ordered from an in-network pharmacy. Sometimes, you may be asked to pay out of pocket for your prescription. Reasons you may be asked to pay out of pocket include:

  • The pharmacy is an out-of-network pharmacy
  • You do not have your member ID card with you, and the pharmacist cannot verify your coverage
  • The medicine is not covered (e.g., not listed as covered in the Prescription Drug Guide)

If you pay for a prescription out of pocket, you can ask us to reimburse you. Fill out and send us a completed Prescription Drug Claim Form for member reimbursement and copies of your receipt(s) to the address on the form.

Prescription Drug Claim Form for member reimbursement, PDF opens new window

We will review your request and decide if reimbursement is possible. This is called making a “coverage decision.” If we decide the expense should be covered, we will pay for the service or drug. If we deny your request for payment, you can appeal our decision.

Learn more about the appeal process

Quality assurance policy and procedures

We want you to get safe, high-quality, and affordable medication. Several policies and procedures make sure this happens.

The Concurrent & Retrospective Drug Utilization Review (DUR) program helps make sure prescriptions are appropriate, medically necessary, and unlikely to have negative medical results.

Learn more about our pharmacy claims processing policies

2021 Transition Policy, PDF opens new window

2022 Transition Policy, PDF opens new window

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Documents & forms

Find the documents and forms you need, including your Member Handbook.