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Documents & Forms

Access your health plan coverage documents, forms needed to manage your claims, and more.

Plan Documents (2021)

Select a Plan to See a List of Available Documents.

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Prescription/Drug Forms

Medication Therapy Management

Drug and/or Utilization Management Information (for plans offering Part D)

(new) OTC Catalog

Prescription Drug Transition Policy

Humana Pharmacy® Registration and Prescription Order Forms

Prescription Drug Guide, Prior Authorization, and Step Therapy Criteria

Concurrent DUR Quality Assurance

Retrospective DUR Quality Assurance

Medicare Prescription Drug Claim Form

Declaration of Prior Prescription Drug Coverage Form

Medicare Part D Coverage Determination and Redetermination Forms

Find out about drug coverage determinations and redeterminations and access our forms.

Determination Form

Redetermination Form

Grievance/Appeal Forms

Grievance/Appeal Request Form

Access our form

Notice of Nondiscrimination

Access our form

Disenrollment Forms

Medicare Advantage Disenrollment Instructions and Form

Both forms below must be completed, signed and returned to Humana for processing.

Medicare Advantage Disenrollment Form

Special Election Period Questionnaire

Other Forms

Health Benefits Claims Form

Access our form with a link

Appointment of Representative Form

You also can get the Appointment of Representative form on the Centers for Medicare & Medicaid Services Website.

Centers for Medicare & Medicaid Services Website

Multi-language Translator Service

Access our form

Multi-language Interpreter Services

Member Blocking Request

Disable the secure member website for yourself or a family member.

Website Blocking Request

Low Income Subsidy Rider

Vision Services Claim Form

Submit vision-related out of pocket expenses for reimbursement.

Note:

Our forms are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to Download Adobe Reader, opens new tab