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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2023 Medicare transition policy

2023 Medicare Transition Policy - English.pdf, PDF

2023 Medicare Transition Policy - Spanish.pdf, PDF

2023 Medicare Transition Policy - Puerto Rico Spanish.pdf, PDF

2023 Medicare Transition Policy – Chinese.pdf, PDF

2023 Medicare Transition Policy – Korean.pdf, PDF

2022 Medicare transition policy

2022 Medicare Transition Policy - English, PDF

2022 Medicare Transition Policy - Spanish, PDF

2022 Medicare Transition Policy - Puerto Rico Spanish, PDF

2022 Medicare Transition Policy – Chinese, PDF

Pharmacy coverage policies

Concurrent DUR Quality Assurance, PDF

Retrospective DUR Quality Assurance, PDF

Humana Part D Direct Member Reimbursement Policy, PDF

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

Prescription claim forms

Medicare Prescription Drug Claim Form - English, PDF

Medicare Prescription Drug Claim Form - Spanish, PDF

Limited Income NET Prescription Drug Claim Form - English, PDF

Limited Income NET Prescription Drug Claim Form - Spanish, PDF

Additional drug info form- English, PDF

Additional drug info form- Spanish, PDF

Drug coverage determination and redetermination

Medicare Part D Coverage Determination Request Form, PDF

Medicare Part D Coverage Redetermination Request Form

Grievance and appeal request forms

Grievance/Appeal Request form - English, PDF

Grievance/Appeal Request form - Spanish, PDF

Appointment of Representative form - English, PDF

Appointment of Representative form - Spanish, PDF