Coverage determination, exceptions and appeals

Coverage determinations are decisions made by Humana as a Medicare Part D plan sponsor and may include whether Humana will cover a drug for a member, the portion of the drug’s cost the member will be responsible for, quantity limits and step therapy requirements. Providers can use the form below to request coverage determination:

Provider Request for Coverage Determination Form – English, PDF opens new window
Provider Request for Coverage Determination Form – Spanish, PDF opens new window

Puerto Rico – Provider Request for Coverage Determination Form – English, PDF opens new window
Puerto Rico – Provider Request for Coverage Determination Form – Spanish, PDF opens new window

Another option is to use the Coverage Determination Request Form, opens external link new window on the Centers for Medicare & Medicaid Services (CMS) website.

Exceptions

Exceptions are a type of coverage determination. Providers should request a tiering exception if they want Humana to cover a nonpreferred drug at the same cost share that would apply to drugs in the preferred tier. Formulary exception requests ask Humana to cover a drug not currently on its Drug List. A formulary exception also may be requested to ask Humana to waive a step therapy drug requirement, or to waive quantity or dosage limits on a drug. For each type of request, the member’s prescriber must submit a supporting statement.

To ask for a standard decision on an exception request, the patient, patient’s physician, another prescriber or the patient’s appointed representative should call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (555-2546). These individuals may also send a written request to:

Humana Clinical Pharmacy Review (HCPR)
ATTN: Medicare Coverage Determinations
P.O. Box 33008
Louisville, KY 40232-3008
Exception requests can be faxed to 877-486-2621.

Prescribers will receive a response to standard exception requests within 72 hours.

Prescribers can submit an expedited request if they believe waiting for a standard decision could seriously jeopardize the patient's life, health or ability to regain maximum function. Expedited requests receive a response within 24 hours. Members who submit an expedited request should include a statement from their prescriber. Reimbursement requests cannot be expedited.

Requests for Puerto Rico members can be submitted via the following methods: Puerto Rico HCPR Humana Health Plans of Puerto Rico, Inc.
P.O. Box 191920
San Juan, PR 00919-1920
Phone: 866-488-5991
Fax: 855-681-8650

Appeals (Part D redetermination) requests

When a prescribing physician or other prescriber disagrees with the outcome of the initial coverage determination or exception request, he or she may request a standard or expedited redetermination. If the prescribing physician or other prescriber making the request is not acting as the patient’s representative, notice of the request must be given to the patient before the request is made. A patient or the patient’s representative may also request a standard or expedited redetermination. Prescribers may do the following within 60 calendar days of the date of the denial notice they received from Humana (unless the filing window is extended):

Request an expedited Part D redetermination

If you believe that waiting 7 days for a standard decision could seriously jeopardize the patient’s life, health or ability to regain maximum function, you can ask for an expedited redetermination, and we will give you a decision within 72 hours. You may request an expedited decision by:

  • Phone: 800-867-6601 (continental U.S.) or 866-773-5959 (Puerto Rico)
  • Fax: 800-949-2961 (continental U.S.) or 800-595-0462 (Puerto Rico)

Request a standard Part D redetermination online

Follow the directions below to use our online Standard Redetermination Form:, opens new window

  1. Enter the prescription drug information.
  2. Indicate the reason you are appealing the denial.
  3. Provide any clinical rationale.
  4. Enter your information.
  5. Attach supporting documentation for your appeal.

If you need to fax supporting documentation, please fax the materials to 877-486-2621 (continental U.S.) or 800-595-0462 (Puerto Rico).

Once Humana receives your request, we will provide written notice of our decision within 7 calendar days.

Request a standard Part D redetermination by phone, fax or mail

Phone: You may file a verbal standard redetermination request by calling us at 800-457-4708 (continental U.S.) or 866-773-5959 (Puerto Rico) (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., local time. Hours of operation from Oct. 15 to Feb. 14 include Saturdays and Sundays, 8 a.m. – 8 p.m.

Request for Redetermination of Medicare Prescription Drug Denial Form, PDF opens new window

Fax: You may file the standard redetermination form via fax to 800-949-2961 (continental U.S.) or 800-595-0462 (Puerto Rico).

Mail: You may file the standard redetermination form via mail at the following addresses:

Continental U.S.: Humana Appeals, P.O. Box 14546, Lexington, KY 40512-4546

Puerto Rico: Humana Appeals, P.O. Box 195560, San Juan, PR 00919-5560

We strongly encourage prescribers to provide additional supporting documentation for redetermination requests.

Once the request is received, Humana will provide written notice of its decision within 7 calendar days for standard requests.

Please refer to CMS’ Part D redetermination process flowchart , opens new window for information on standard and expedited time limits.

Questions

If you have questions regarding the redetermination process, please call 866-773-5959 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., local time. Hours of operation from Oct. 15 to Feb. 14 include Saturdays and Sundays, 8 a.m. – 8 p.m.

Instructions for submitting a request for reconsideration to the independent review entity

If you disagree with our decision to maintain the denial, you may request a review of the case by the Center for Health Dispute Resolution (C2C Innovative Solutions Inc.), the CMS contractor, for an independent review and determination.

You must submit a written request to C2C Innovative Solutions Inc. within 60 calendar days of our decision. You may request either a standard or an expedited reconsideration from the independent review organization.

An enrollee, an enrollee’s representative, an enrollee’s prescribing physician or another prescriber may request a reconsideration.

To request a reconsideration, you should submit your request to the following:

Continental U.S. and Puerto Rico:

C2C Innovative Solutions Inc. Part D Drug Reconsiderations
P.O. Box 44166
Jacksonville, FL 32231-4166
Phone: 833-919-0198 (toll-free)
Fax: 833-710-0580

Humana contact information

Physicians who have questions about the grievance, appeals or exceptions process or who would like to obtain an aggregate number of grievance, appeals or exceptions filed under the plan should contact the Customer Care phone number on the back of the member’s ID card.

Medicare Advantage prescription drug plan members can call 800-457-4708 (continental U.S.) or 866-773-5959 (Puerto Rico), and prescription-drug-plan-only members can call 800-281-6918 (continental U.S.) or 866-773-5959 (Puerto Rico).