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Documents and forms for Humana Healthy Horizons in Louisiana Members

Find the documents and forms you need to get the most from your health plan.

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Key plan documents

Change of address form

If your home or mailing address changes, you have to let the Louisiana Department of Health (LDH) know. If you don’t, you may lose your coverage or miss out on key health plan information and reminders. After completing the form, you can return it by email or fax.

Louisiana Department of Health Change of Address form, PDF

Or, to update your information through us, call us at 1-800-448-3810 (TTY: 711), Monday – Friday, from 7 a.m. – 7 p.m.

Welcome Kit/Quick Start Guide

All new members get a Welcome Kit/Quick Start Guide in the mail. You also can view it below. Your Welcome Kit/Quick Start Guide includes the information you need at the start of your enrollment in Humana Healthy Horizons® in Louisiana

Welcome Kit/Quick Start Guide – English, PDF

Welcome Kit/Quick Start Guide – Spanish, PDF

Adobe Reader is needed to view PDFs. If you do not have Adobe Reader, download it today.

Health Needs Assessment (HNA)

The HNA is a set of health questions for you to answer. Your answers will help us make sure you get the care you need. Your Welcome Kit/Quick Start Guide includes an HNA and a postage-paid envelope in which to return it.

Health Needs Assessment – English, PDF

Health Needs Assessment – Spanish, PDF

Earn $30 in rewards through Go365 for Humana Healthy Horizons® if you complete your HNA during the first 90 days of enrollment in Humana Healthy Horizons® in Louisiana

Learn more about Go365 for Humana Healthy Horizons

Member Handbook

Refer to your Member Handbook for information your plan, benefits, and covered services

Member Handbook – English, PDF

Member Handbook – Spanish, PDF

Provider directories

To find information about in-network doctors, specialists, and healthcare facilities near you:

Watch a short video about using our Find a Doctor service

To use our online Find a Doctor tool go to

Enter your ZIP code, select Medicaid as your coverage type, and select Network from the drop-down menu.

You can then search by the name of the doctor or facility, specialty, such as cardiology, or a condition such as ear infection.

You also can choose All and type any text into the search.

Then click Search.

Click Update my search to search for something else.

If you need help finding and choosing a doctor, call the number on the back of your enrollee ID card to speak with an Enrollee Services representative.

Region 1 - Metropolitan: Jefferson, Orleans, Plaquemines, and St. Bernard parishes

Region 2 – Capital Area: Ascension, East Baton Rouge, East Feliciana, Iberville, Pointe Coupee, West Baton Rouge, and West Feliciana parishes

Region 3 – South Central: Assumption, Lafourche, St. Charles, St. John the Baptist, St. James, St. Mary, and Terrebonne parishes

Region 4 – Acadiana Area: Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, and Vermillion parishes

Region 5 – Imperial Calcasieu: Allen, Beauregard, Calcasieu, Cameron, and Jefferson Davis parishes

Region 6 – Central: Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, and Winn parishes

Region 7 – Northwest: Bienville, Bossier, Caddo, Claiborne, Desoto, Natchitoches, Red River, Sabine, and Webster parishes

Region 8 – Northeast Delta: Caldwell, East Carroll, Franklin, Jackson, Lincoln, Madison, Morehouse, Ouachita, Richland, Tensas, Union, and West Carroll parishes

Region 9 – Florida Parishes: Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington parishes

Primary care provider change request form

To change your primary care provider (PCP), use our online PCP change request service in your MyHumana account (desktop version only) or complete and submit the PCP Change Request Form.

PCP Change Request Form, PDF

Pharmacy information and resources

Preferred Drug List (PDL)

The Louisiana Department of Health (LDH) PDL:

The LDH Single PDL is a list of medicine Louisiana Medicaid recipients can use if prescribed. A Pharmacy and Therapeutics (P&T) Committee recommends medicine to include on or remove from the PDL. Medicine on the PDL is identified as preferred or nonpreferred and includes information about prior authorization requirements.

Review the current LDH Single PDL, PDF

Please note: The LDH Single PDL is not all-inclusive. Many medications listed on the single PDL are covered.

Over-the-counter (OTC) catalog and order form

Humana Healthy Horizons in Louisiana members:

  • Have a $25/month allowance to spend on OTC health and wellness items through the mail
  • Can use Humana’s mail-order pharmacy, CenterWell Pharmacy™, which will send medicine to your home

To get started:

  • Look up available OTC items in the Humana Health and Wellness Catalog

Humana Health and Wellness Catalog and Order Form – English, PDF

Humana Health and Wellness Catalog and Order Form – Spanish, PDF

  • Follow directions on the form to submit your order to us

Health benefits claim form

To request reimbursement of out-of-pocket expenses tied to a Humana Healthy Horizons in Louisiana covered benefit, please complete and return a Health Benefits Claim Form.

Health Benefits Claim Form, PDF

Expanded Benefits Reimbursement Form

We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Louisiana member. If you do, let us know by filling out a reimbursement claim form, and you may get a refund.

Fill out the form below to send a reimbursement claim.

Expanded Benefits Reimbursement Form – English, PDF

Expanded Benefits Reimbursement Form – Spanish, PDF

Grievances and appeals forms

We want you to be happy with the care you get. We hope you get the best care possible.

If you are not happy with any part of your healthcare plan, Member Services, your doctor, or a facility, you can send in a grievance.

You also can appeal a claim or a denied service using the grievances and appeals forms.

To have someone send an appeal or grievance for a covered member, we must have a completed Appointment of Representative Form, PDF on file.

Learn more about grievances and appeals, and access our form for submitting a grievance or appeal online

Legal and privacy notices

The legal and privacy notices below provide information about:

  • How Humana uses, and when we might share, your personal information
  • Your privacy rights

Individual privacy rights – English, PDF

Individual privacy rights – Spanish, PDF

Rights and responsibilities – English, PDF

Rights and responsibilities – Spanish, PDF

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – English, PDF

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – Spanish, PDF

HIPAA Privacy Complaint Form, PDF

To give us permission to share your medical information with someone, you must complete and send back to us a Consent for Release of Medical Information and a Consent for Release of Protected Health Information

Consent for Release of Medical Information – English, PDF

Consent for Release of Medical Information – Spanish, PDF

Consent for Release of Protected Health Information – English, PDF

Consent for Release of Protected Health Information – Spanish, PDF

Detecting, preventing, and reporting healthcare fraud

As part of our efforts to improve the healthcare system, we are committed to:

  • Detecting, correcting, and preventing healthcare fraud
  • Educating our members about how to detect and/or prevent fraud

Learn more about detecting, preventing, and reporting healthcare fraud and how you can help, PDF

Performance measurement

Refer to the below information to see:

How we’re measured as a health plan and

How we’re doing

Guide to Healthcare Effectiveness Data and Information Set (HEDIS®) measurements

State of Health Care Quality Report (NCQA)

Looking for help?

Contact us

If you have questions, find the number you need to get help and support.

Find a doctor

Find a doctor, hospital, or pharmacy.

Find a dentist

Use this Find a Dental Provider service to find a dentist near you.