Part-d Coverage Redetermination

Medicare Part D (Drug) Coverage Redetermination (Appeal)

When can I appeal an unfavorable drug coverage determination?

If you have received an unfavorable drug determination, you can ask for redetermination (appeal) by following the instructions given in the determination or as outlined below. Some reasons you may want to ask for a redetermination may be for formulary exceptions, coverage rule exceptions, or tiering exceptions.

Can I file an expedited appeal on an unfavorable drug coverage determination?

An expedited appeal can be requested for situations in which the standard resolution timeframe could seriously jeopardize your (member) life or health, or the ability to regain maximum function. Refer to the Expedited Appeal section.

Who can submit the Part D coverage redetermination request?

You (member), a person you appoint, your prescribing doctor, or other prescriber can submit the Part D coverage redetermination request. Refer to the How to Appoint a Representative section for additional information.

How can I submit the reconsideration request?

  • Submit your request online. Fill out the Coverage Redetermination Request Form. It's fast, easy, and secure. You'll need the following:
    1. Your prescription drug information.
    2. The reason you're appealing the denial.
    3. Any clinical rationale given to you by your prescribing doctor or other prescriber. You can add this as an attachment in the online form or fax it to us at 1-855-251-7594. If you live in Puerto Rico, use fax number 1-800-595-0462.
    4. The prescribing doctor's information.

    Before filling out the form, please view our accepted file types.

    Coverage Redetermination Request Form

  • Fax or mail the form. Download a copy of the following form and fax or mail it to Humana.

    Coverage Redetermination Request Form
    Download PDF
    English | Spanish

    Fax Number: 1-855-251-7594

    Mailing Address:
    Humana Grievances and Appeals
    P.O. Box 14165
    Lexington, KY 40512-4165

    Puerto Rico Members: Use the following form, fax and/or mailing address.

    Coverage Redetermination Request Form – Puerto Rico
    Download PDF
    English | Spanish

    Fax Number: 1-800-595-0462

    Mailing Address:
    Humana Puerto Rico
    Grievances and Appeals Unit
    P.O. Box 191920
    San Juan, PR 00919-1920

  • Call the number on the back of your ID card. You can submit a redetermination by calling Customer Service. You can also get help with any questions or problems you have filling out the form. Call Customer Service toll free at the number on the back of your ID card. If you have a speech or hearing impairment and use a TTY, call 711. Puerto Rico members, call 1-866-773-5959. Our hours are 8 a.m. to 8 p.m. Monday through Friday EST.

    Be sure to submit all supporting information for your appeal request. You or your prescribing doctor or other prescriber can send this to fax number 1-855-251-7594. If you live in Puerto Rico, please fax to 1-800-595-0462. After we receive the request, Humana will make our decision and send written notice within seven calendar days.

Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in a Humana plan depends on contract renewal.

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