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 drug list 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 time frame could seriously jeopardize your (or the member’s) life or health, or the ability to regain maximum function. Refer to the Expedited appeal page.
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
It's fast, easy and secure to submit your request online, through fax or by mail. First, download the Coverage Redetermination Form:
Include the following information on the form:
- Your prescription drug information.
- The reason you're appealing the denial.
- 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.
- The prescribing doctor's information.
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 5 a.m. to 8 p.m. EST, 7 days a week.
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.