Medical and pharmacy preauthorizations

Depending on your plan, you may need to ask Humana if we cover certain medical services or prescriptions before you receive them.

For medical services, it’s called “medical organization determination.” For medications, it’s called “pharmacy prior authorization.” These requests must happen before you receive service—unless it’s an emergency. 

Here are some helpful details for medical and pharmacy preauthorizations.

Medical organization determinations

Does my service require a coverage decision?

For certain medical procedures, services or medications, your doctor or hospital need advanced approval from Humana before your plan covers any of the costs. The services that require advance approval are included in your Evidence of Coverage. You can also contact us to find out if the services you need are covered in your Humana plan.

Medicare members—Call the number on the back of your Humana member ID card to determine what services and medications require authorization.

View the ASAM criteria for patients and families. This pamphlet is provided for information only and is posted to comply with IL HB 2595.

How do I submit a standard coverage decision?

You, your representative or your doctor can ask us for a coverage decision by calling, faxing or mailing your request to us. 

  • Phone—Call 800-457-4708 (TTY: 711), 7 days a week, 8 a.m. – 8 p.m., Eastern time. For expedited coverage decisions, call 866-737-5113.
    If you belong to a Group Medicare plan, please contact the number on the back of your member ID card (TTY: 711), Monday – Friday, 8 a.m. – 9 p.m., Eastern time. 
  • Fax—888-200-7440. Contact us by fax for expedited coverage decisions only.
  • Mail—Humana
    P.O. Box 14168
    Lexington, KY 40512-4168

How long does it take to get a standard coverage decision?

We’ll give you an answer within 14 days of receiving your standard coverage decision request. 

How do I request an expedited coverage decision?

If your doctor tells Humana that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own, without your doctor’s support, we will decide whether your health requires us to give you a fast coverage decision.

  • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so and that we will use the standard deadlines instead.
  • This letter explains that we will automatically give a fast coverage decision if your doctor asks for it.
  • The letter will also explain how you can file a “fast complaint” about our decision to give you a standard-deadline coverage decision. When you file a fast complaint, we will answer your complaint within 24 hours.

How long does it take to get an expedited coverage decision?

If you think your health could be seriously harmed or that you could lose your ability to function by waiting the standard 14 days for a decision, you can ask for an “expedited” decision. We will give you an answer with 72 hours after we receive your request for a fast coverage decision.

What if Humana needs extended time for a coverage decision?

We can take up to 14 more calendar days to make either a standard or fast decision if you ask for more time or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.

If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will answer your complaint within 24 hours.

If we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.

What if Humana says they won’t cover a service?

In some cases, we might decide a service is not covered or is no longer covered by your plan. If we say no to part or all of what you requested, we will send you a detailed written explanation and instructions on how to appeal our decision. See more information about how to file an appeal.

Pharmacy prior authorizations

Why is prior authorization required?

Certain high-risk or high-cost medications require prior authorization by the Humana Clinical Pharmacy Review (HCPR) to be eligible for coverage. This is to ensure that the drugs are used properly and in the most appropriate circumstances. Prior authorization criteria are established by Humana’s Pharmacy and Therapeutics committee with input from providers, manufacturers, peer-reviewed literature, standard compendia, and other experts.

How can I get prior authorization for my prescription?

In order for you to receive coverage for a medication requiring prior authorization, follow these steps:

  1. Use the Medicare Drug List to determine if your prescription drug requires prior authorization for coverage.
  2. If it is required, ask your doctor to submit the request. Your doctor can submit the request online, by fax, or by phone by accessing our Provider's Prior Authorization information.

Once your request has been processed, your doctor will be notified. If you are a Medicare member, you will also receive a determination letter in the mail

Important timeframes for appeals

  • Part C— You have 65 days from the date of our Notice of Denial of Medical Coverage (or Payment) to appeal. After we receive the request, Humana will make a decision and send written notice within the following timeframes:
    • Pre-Service Appeal—30 Calendar Days
    • Post Service Appeal—60 Calendar Days
  • Part D—You have 65 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to appeal (ask us for a redetermination). After we receive the request, Humana will make a decision and send written notice within 7 calendar days.

How to appoint a representative to file for you

For Humana to consider an appeal or grievance from someone other than you, we must have a valid authorization. You can appoint anyone as your representative by signing and sending us 1 of the following forms:

A representative who is appointed by the court or who is acting in accordance with state law also can file a request on your behalf after sending us the appropriate legal representative document. Note: You don’t need to complete an Appointment of Authorized Representative form if you provide a valid legal representation document with your request.

How to appeal a Part D late enrollment penalty from the Centers for Medicare & Medicaid Services (CMS)

If you received a Part D late enrollment penalty, you can appeal the decision with CMS if you meet certain conditions. Learn more about Part D late enrollment penalty reconsideration to see if you qualify, how to appeal this decision and more. 

Utilization management

Utilization management is used to determine whether a service or treatment is medically necessary and appropriate for payment under your benefit plan. Humana does not reward or provide financial incentives to doctors, other individuals or Humana employees for denying coverage or encouraging under use of service. 

If you have questions or disagree with a coverage decision, call Member Services at the number on your ID card.