Documents & 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.

Grievance/Appeal Request Form

Access our form

Notice of Nondiscrimination

Access our form

Medicare Advantage Disenrollment Instructions and Form

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

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.

Multi-language Translator Service

Access our form

Member Blocking Request

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

Low Income Subsidy Rider

Vision Services Claim Form

Submit vision-related out of pocket expenses for reimbursement.