Some Prescription Drugs Require Authorization

Some drugs need a coverage determination. If your drug needs this step, you or your doctor will need to ask for and get advance approval from Humana to cover the drug. If you have already had an unfavorable drug determination, you can ask for redetermination.

Drug Coverage Determination

Why is a drug coverage determination needed?

To ensure the most appropriate drug use, some high-risk or high-cost drugs need prior approval by Humana Clinical Pharmacy Review (HCPR) to be covered. The Humana Pharmacy and Therapeutics committee sets the criteria with input from doctors, manufacturers, peer-reviewed literature, research, and other experts.

To find out if your prescription needs a drug determination, go to Humana's Medicare Drug List Search

Coverage Determination Request

To get a drug coverage determination, you, a person you appoint, or your prescribing doctor can contact Humana in one of these ways:

  • Ask your prescribing doctor to send in the request for you – He/She can submit the request online by filling out the Coverage Determination Request Form, or by fax or by phone by going to our Provider's Prior Authorization.
  • Submit your request online – Fill out the Coverage Determination Request Form. You'll need to send us supporting documentation from the prescribing doctor to show medical need. Your information will be sent to us securely. Before filling out the form, you may want to review our accepted file types.

    Important Note: If you are requesting a formulary, tiering exception or prior authorization, ask the prescribing physician to complete the Coverage Determination Request for you. He or she will need to provide supporting information with the request.

    Coverage Determination Request Form

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

    Coverage Determination Request Form
    Download PDF
    English | Spanish

    Fax number: 1-877-486-2621

    Mailing address:
    Humana Clinical Pharmacy Review (HCPR)
    P.O. Box 33008
    Louisville, KY 40232-3008
    Puerto Rico members: Use the following form.

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

    Fax number: 1-866-423-0486

    Mailing address:
    Humana Puerto Rico
    Humana Clinical Pharmacy Review (HCPR) – Puerto Rico
    P.O. Box 191920
    San Juan, PR 00919-1920

  • Call HCPR at 1-800-555-CLIN (2546) – Hours are 8 a.m. to 6 p.m., in your local time zone, Monday through Friday. Puerto Rico members, call 1-866-488-5991 8 a.m. to 6 p.m., Monday through Friday. Extended coverage from Oct. 15, 2012–Feb. 14, 2013, is available from 8 a.m. to 8 p.m. on Sunday. If you use a TTY, call 711.

After we process your request, you and your doctor will receive a determination letter.

Drug Coverage Redetermination

How to appeal an unfavorable drug coverage determination

If you have received an unfavorable drug determination, you can ask for redetermination. You can use the Part D Coverage Redetermination Request form to appeal. Redeterminations can be requested because of unfavorable formulary exceptions, coverage rule exceptions, or tiering exceptions.

Part D Coverage Redetermination Request

To ask for a drug coverage redetermination, you, a person you appoint, your prescribing doctor, or other prescriber can contact Humana in one of these ways:

  • 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 1-800-949-2961. If you live in Puerto Rico, use fax number 1-800-595-0462.
    4. The prescribing doctor's information.

    Before filling out the form, you may want to view our accepted file types.

    Coverage Redetermination Request Form

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

    Coverage Redetermination Request Form
    Download PDF
    English | Spanish

    Fax number: 1-800-949-2961

    Mailing address:
    Humana Grievances and Appeals
    P.O. Box 14165
    Lexington, KY 40512-4165
    Puerto Rico members: Use the following form.

    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 – Hours are 8 a.m. to 8 p.m. Monday through Friday. Extended coverage from Oct. 15, 2012–Feb. 14, 2013, is available from 8 a.m. to 8 p.m. Saturday and Sunday. If you use a TTY, call 711. Puerto Rico members, call 1-866-773-5959 8 a.m. to 8 p.m. Monday through Friday.

    Be sure to send other supporting information for your appeal. You or your prescribing doctor or other prescriber can send this to fax number 1-855-251-7594 or 1-800-595-0462 if you live in Puerto Rico.

    After we receive the request, Humana will make our decision and send written notice within seven calendar days for most requests.

    You can 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. Our hours are 8 a.m. to 8 p.m. Monday through Friday. Extended coverage from Oct. 15, 2012–Feb. 14, 2013, is available from 8 a.m. to 8 p.m. Saturday and Sunday. Puerto Rico members, call 1-866-773-5959 8 a.m. to 8 p.m. Monday through Friday.

How to Appoint a Representative

We must have authorization to review a Part D coverage determination or redetermination request from someone other than the member, their prescribing doctor, or other prescriber. You can appoint anyone by sending us an Appointment of Representative form signed by you and the representative. A representative who is appointed by the court or who is acting under state law can also file a request for you after sending us the legal representative form. You don't need to complete an Appointment of Representative Form if you send another legal representation document with your request.

Appointment of Representative
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You also can get the Appointment of Representative and Request for Coverage Determination forms on CMS's website.

Refer to Chapter 9 of your Evidence of Coverage (EOC) for more information about the grievance, coverage determination (including exceptions), and appeals processes.

Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract.

Find out if a prescription drug is covered under your Humana plan.

Already a Humana member?

Register with MyHumana to print ID cards, check claims, and get information you need anytime.

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Drug Pricing

Log in to MyHumana to find out if your plan covers a certain prescription drug and view estimated prices, based on the pharmacy you select.

Drug Pricing Tool
Info on Part D coverage re determination request with authorization details

Appointment of Representative Form

To consider a Part D coverage determination or redetermination request from someone other than the member, we must have authorization.

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