Pharmacy

Pharmacy, prescription, and medication benefits and information.

Humana works with you and your doctor to make sure you get the medications you need. The Drug Guide includes the drugs covered by the Humana Gold Plus Integrated, A Commonwealth Coordinated Care Plan (Medicare-Medicaid Plan).

You will sometimes have to pay for your prescriptions. There are also limits to your drug benefits.

Why do some drugs have limits?

For certain prescription drugs, special rules limit how and when the plan covers them.  In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective.  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. If you don’t get approval, Humana Gold Plus Integrated may not cover the drug.

How do I know if a drug requires prior authorization?

You can:

Information on Requesting a Coverage Determination

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

You can request a prior authorization by contacting us directly through our Humana Clinical Pharmacy Review department or through your doctor.

Fax number: 1-877-486-2621

Mailing address: Humana Clinical Pharmacy Review (HCPR) P.O. Box 33008 Louisville, KY 40232-3008

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, you could also be taking medicines that, when combined, may:

  • Reduce the effectiveness of your medicine
  • Cause severe side effects
  • Cost you more money per month

As part of your Part D coverage with Humana, you can set up a one on one review of your medicines with a pharmacist. This review is call Medication Therapy Management (MTM) and is offered at no extra cost to you.

You’ll stay up to date through monthly mailings. Some of our members even qualify for face-to-face or over the phone help.

More information on MTM

What is the plan's Prior Authorization and Step Therapy Criteria?

Can you use mail-order services to get your drugs?

For certain kinds of drugs, you can use the plan's network mail-order services available through Humana RightSource. 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 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 Care at 1-855-280-4002 (TTY: 711). We're available Monday – Friday, from 8 a.m. – 8 p.m. Eastern time. However, please note that our automated phone system may answer your call after hours, during weekends, and holidays. Please leave your name and telephone number, and we'll call you back by the end of the next business day.

Monthly Over-the-Counter Supplemental Benefit​

You are eligible for up to a $35 monthly benefit to be used toward the purchase of over-the-counter (OTC) health and wellness products available through Humana RightSource, our mail order pharmacy. The order form can be obtained by calling Customer Care or by using the form below.

Best Available Evidence (BAE) policy

These are rules that specify the requirements of Part D plans in the administration of the low-income subsidy 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 (LIS) status, also known as ‘extra help’. As a result, the right subsidy information has not been shared with the Part D plan. To help with the situation, CMS created the Best Available Evidence (BAE) policy. This policy requires sponsors (health plans) to correct the cost-sharing for low-income beneficiaries when presented with proof that your information is not right.

Best Available Evidence (BAE) (link opens in new window) 

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. Read more about them here:

Learn how Humana makes sure medications are used safely, effectively, and correctly. (58.1 Kb)

The Retrospective Drug Utilization Review (DUR) program (95 Kb) was created to improve health outcomes. It does this by making sure prescriptions are appropriate, medically necessary, and unlikely to have bad medical results.

Pharmacy Claim Form