Medicare policies and claim forms for prescription drugs

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

You must have Adobe Reader to view and print these documents.

2021 Medicare transition policy

2021 Medicare Transition Policy - English, opens PDF in new window

2021 Medicare Transition Policy - Spanish, opens PDF in new window

2021 Medicare Transition Policy - Puerto Rico Spanish, opens PDF in new window

2021 Medicare Transition Policy – Chinese, opens PDF in new window

2020 Medicare transition policy

2020 Medicare Transition Policy – English, opens PDF in new window

2020 Medicare Transition Policy – Spanish, opens PDF in new window

2020 Medicare Transition Policy – Puerto Rico Spanish, opens PDF in new window

Pharmacy coverage policies

Concurrent DUR Quality Assurance, opens PDF in new window

Retrospective DUR Quality Assurance, opens PDF in new window

Humana Part D Direct Member Reimbursement Policy, opens PDF in new window

Póliza de reembolso directo para afiliados de Humana con cobertura para medicamentos recetados bajo la Parte D, opens PDF in new window

Prescription claim forms

Medicare Prescription Drug Claim Form - English, opens PDF in new window

Medicare Prescription Drug Claim Form - Spanish, opens PDF in new window

Limited Income NET Prescription Drug Claim Form - English, opens PDF in new window

Limited Income NET Prescription Drug Claim Form - Spanish, opens PDF in new window

Drug coverage determination and redetermination

Medicare Part D Coverage Determination Request Form, opens PDF in new window

Medicare Part D Coverage Redetermination Request Form, opens new window

Grievance and appeal request forms

Grievance/Appeal Request form - English, opens PDF in new window

Grievance/Appeal Request form - Spanish, opens PDF in new window

Appointment of Representative form - English, opens PDF in new window

Appointment of Representative form - Spanish, opens PDF in new window