Exceptions and Appeals

Request a Coverage Determination for a Prescription Drug

Exceptions

To ask for a standard decision, you, your doctor, or your appointed representative should call Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546), or you can deliver a written request to:

Humana Clinical Pharmacy Review (HCPR)
ATTN: Medicare Coverage Determinations
1951 Bishop Lane
Suite 500
Louisville, KY 40218

You may also fax it to 1-877-486-2621

Member request for Coverage Determination Form

(89.9 KB) Download PDF
English

Grievances

A grievance is a complaint expressing dissatisfaction with any aspect of the plan.

What types of problems might lead to you filing a grievance?

You feel that you are being encouraged to leave (disenroll from) Humana;
Problems with the Member Service you receive;
Problems with how long you have to spend waiting on the phone or in the pharmacy;
Disrespectful or rude behavior by pharmacists or other staff;
Cleanliness or condition of pharmacy;
If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination;
You believe our notices and other written materials are difficult to understand;
Failure to give you a decision within the required timeframe;
Failure to forward your case to the independent review entity if we do not give you a decision within the required timeframe;
Failure by us to provide required notices; or
Failure to provide required notices that comply with CMS standards.

Grievances must be filed within 60 days of occurrence.

Direct your written grievance to the following address:

Humana Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4546
Fax # 1-800-949-2961

You may also file a verbal grievance by calling:
1-800-457-4708 or
TDD# 1-800-833-3301 (hearing impaired)

Include your name, address, telephone number, Humana ID number and the reason for the grievance in your letter. Please include any supporting notes or documents that may support your request. We will investigate your grievance and inform you of our decision.

Appeals

If you disagree with our decision to deny payment of a claim or coverage for a prescription drug, you may file an appeal to request that we reconsider our initial decision.

You have the right to appeal our decision if you think the following:

We are stopping or reducing coverage for a drug.
We will not authorize coverage for a drug we should cover.
We have not paid a bill we should pay.
We have not paid a bill in full that we should have paid in full.
We have denied an exception request and you disagree; or
We are not making a decision within the required time frame.

Within 60 calendar days of the date of the denial notice you received from us, submit your appeal in writing to the following address:

Humana Appeals
P.O. Box 14546
Lexington, KY 40512-4546
Fax # 1-800-949-2961

For questions regarding the appeals process, please call:
1-800-457-4708 or
TDD# 1-800-833-3301 (hearing impaired).
*Please note that appeals may only be requested in writing.

Include your name, address, Humana ID number and the reason for the appeal in your letter. Please include any supporting notes or documents that may support your request. We will investigate your appeal and inform you of our decision.

Instructions for Submitting a Request for Reconsideration to the IRE

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 (MAXIMUS), the Centers for Medicare & Medicaid Services (CMS) contractor, for an independent review and determination.

You must submit a written request to MAXIMUS within 60 calendar days of our decision. You may request either a standard appeal (reconsideration) or an expedited appeal (fast reconsideration) from the independent review organization.

To request a reconsideration, you should submit your request to MAXIMUS at the address or fax number listed below:

For members of a Part D Prescription Drug Plan:
MAXIMUS
1040 First Avenue
Suite 200
King of Prussia, PA 19406
Fax # 1-484-688-5601

For members of a Medicare Advantage Prescription Drug Plan:

MAXIMUS
50 Square Drive
Victor, NY 14564
Fax # 1-585-425-5301

Instructions about How to Appoint a Representative

Appointment of Representation Form

(1691 KB) Download PDF
English

To consider a request from someone other than the member, we must have authorization. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

About Prior Authorization

Some drugs within Humana's Formulary are considered to have a Prior Authorization. If your drug has a prior authorization, your prescription may not be covered unless your doctor requests and receives approval from Humana.
For drugs that require prior authorization, the doctor must contact Humana by one of the two following ways:

Phone in the request by calling HCPR at 1-800-555-CLIN (2546) between the hours of 8:00am to 9:00 pm EST Monday through Friday
The provider must complete the form in its entirety, and include a supporting statement of medical necessity. The supporting statement may include specific patient medical information as well as peer reviewed literature related to the request if applicable.

The form must be either mailed to:
Humana Clinical Pharmacy Review
1951 Bishop Lane
Suite 500
Louisville, KY 40218

It may faxed to: 1-877-486-2621.

Prior Authorization Fax Form

(34 KB) Download PDF
English

About Step Therapy

With step therapy drugs, Humana requests that you try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Humana may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Humana will cover Drug B.

2007 Medicare National Drug Guide

(142 KB) Download PDF
English

Contact

For 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, please contact the customer service phone number on the back of the member's ID card.

Medicare Advantage Prescription Drug plan members can call 800-457-4708 and Prescription Drug plan only members can call 800-281-6918 directly.

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