Medicare policies and claim forms for prescription drugs

View pharmacy coverage policies, reimbursement and prescription claim forms for your Medicare plan.

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2025 Medicare transition policy

2025 Medicare Transition Policy - English.pdf

2025 Medicare Transition Policy - Spanish.pdf

2025 Medicare Transition Policy - Puerto Rico Spanish.pdf

2025 Medicare Transition Policy – Chinese.pdf

2025 Medicare Transition Policy – Korean.pdf

Pharmacy coverage policies

Concurrent DUR Quality Assurance

Retrospective DUR Quality Assurance

Humana Part D Direct Member Reimbursement Policy

Póliza de reembolso directo para afiliados de Humana con cobertura para medicamentos recetados bajo la Parte D)

Prescription claim forms

Medicare Prescription Drug Claim Form - English

Medicare Prescription Drug Claim Form - Spanish

Limited Income NET Prescription Drug Claim Form - English

Limited Income NET Prescription Drug Claim Form - Spanish

Additional drug info form- English

Additional drug info form- Spanish

Drug coverage determination and redetermination

Medicare Part D Coverage Determination Request Form

Medicare Part D Coverage Redetermination Request Form

Grievance and appeal request forms

Grievance/Appeal Request form - English

Grievance/Appeal Request form – Chinese

Grievance/Appeal Request form - Spanish

Appointment of Representative form - English

Appointment of Representative form - Spanish

Pharmacy Resources