Member forms

This page links you to the forms Humana Medicare members need most often.

Limited Income NET Pharmacy Claim form
(650 KB) Download PDF
English

Medicare Part D Coverage Determination and Redetermination forms
Find out about drug coverage determinations and redeterminations and access our forms.
Medicare Part D Coverage Determination and Redetermination

Grievance/Appeal Request Form
(42 KB) Download PDF
English

Appointment of Representative Form
(1.6 MB) Download PDF
English

You also can get the Appointment of Representative form on CMS's website

Medicare Part D Coverage Determination and Redetermination forms

Find out about drug coverage determinations and redeterminations and access our forms.

Medicare Part D Coverage Determination and Redetermination

Note: Our forms are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to Download Adobe Reader