Humana's Drug Coverage Depends on Your Plan Type

Humana covers prescription drugs through two different routes depending on which Medicare plan you have. If you have a Medicare Advantage plan (Part C) with Humana, drug coverage is built into that plan. If you have Original Medicare (Part A and B), you need a separate Prescription Drug Plan (Part D) from Humana to cover medications. The drugs Humana will pay for are listed in a document called a formulary, which changes every year on January 1st.

You cannot see the full formulary without knowing which specific Humana plan you are considering. Humana offers dozens of Medicare Advantage and Part D plans, and each one has its own list of covered drugs, cost-sharing amounts, and pharmacy networks. The drug your doctor prescribes might be covered under one Humana plan but not another, or covered at different prices.

Key Takeaways

  • Humana's covered drugs are listed in a formulary specific to your plan, and you must check the formulary for your exact plan before enrolling.
  • Medicare Advantage plans from Humana include drug coverage as part of the plan; Original Medicare requires a separate Part D plan from Humana.
  • Humana formularies change every January 1st, so a drug covered this year may not be covered next year, or its cost-sharing may change.
  • You can view Humana's formularies and compare plans on Medicare.gov or by calling Humana directly at the number on your plan materials.
  • If your drug is not covered or costs too much, you can ask your doctor for a different drug on the formulary, or request an exception from Humana.

How to Find Humana's Drug Formulary for Your Plan

Start by identifying which Humana plan you have or are considering. If you already have a Humana Medicare plan, the plan name and number appear on your insurance card. If you are shopping for a new plan, you will need to decide whether you want Medicare Advantage or Part D coverage first.

Go to Medicare.gov and use the Plan Finder tool. Enter your ZIP code, select Humana as the insurance company, and the tool will show you every Humana plan available in your area. Click on any plan name to see its formulary. You can also search for a specific drug by name, and the tool will tell you which Humana plans cover it and at what cost-sharing level.

If you prefer to speak with someone, call Humana's Medicare customer service number. The number is on your insurance card if you are already enrolled, or you can find it on Humana's website. Humana representatives can email or mail you a formulary, or read drug coverage information over the phone. Ask them to confirm whether your specific medications are covered and what you will pay out of pocket.

Understanding Formulary Tiers and Cost-Sharing

Humana organizes covered drugs into tiers, and your out-of-pocket cost depends on which tier your drug is on. A typical formulary has four to five tiers. Tier 1 drugs (usually generic medications) cost the least. Tier 2 and 3 drugs (brand-name and some generics) cost more. Tier 4 and 5 drugs (expensive brand-name and specialty medications) cost the most.

Your cost-sharing for each tier is set in your plan documents and may be a fixed copay (for example, $10 for a Tier 1 drug) or coinsurance (a percentage of the drug's cost, such as 25%). Some plans use a combination: a copay for the first fill, then coinsurance after that. The cost-sharing amounts reset every calendar year on January 1st.

Humana also places some drugs on a prior authorization requirement, meaning your doctor must contact Humana and get approval before the pharmacy will fill the prescription. Other drugs may have a step therapy requirement, meaning you must try a cheaper drug first, and only if that does not work can you move to the more expensive one. These requirements are listed in the formulary.

What Happens When Your Drug Is Not on the Formulary

If Humana does not cover the drug your doctor prescribed, you have three main options. First, ask your doctor whether there is a similar drug on Humana's formulary that would work for your condition. Your doctor can check the formulary or call Humana to find alternatives. This is often the fastest solution.

Second, you can request a formulary exception from Humana. Your doctor submits a written request explaining why you need the specific drug — for example, because you have tried other drugs on the formulary and they did not work, or because you have a medical condition that requires this particular medication. Humana reviews the request and decides whether to cover it. The process usually takes 24 to 72 hours for urgent requests and up to 7 days for standard requests.

Third, if Humana denies the exception, you can pay for the drug out of pocket, or you can switch to a different Humana plan that does cover it. Plan switching is only possible during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event.

When Formularies Change and How to Stay Informed

Humana updates its formularies every year, effective January 1st. A drug that was covered in December may not be covered in January, or its tier and cost-sharing may change. Humana is required to notify you of major changes by October 15th of the year before the change takes effect, but the notification is often a dense document that is straightforward to miss.

To stay informed, log into your Humana account online and check your plan's formulary in October. Look for any drugs you take regularly and note whether they are still covered and at what cost. If a drug you depend on is being removed or moved to a higher tier, contact Humana when ready to discuss alternatives or request an exception.

You can also set up a reminder on your calendar for mid-October to review your medications. If you take multiple drugs, write them down and check each one against the new formulary before January 1st. This gives you time to work with your doctor on a plan if changes are coming.

Medicare Advantage Plans vs. Part D Plans: Drug Coverage Differences

If you have a Humana Medicare Advantage plan, drug coverage is included as part of the plan. You pay a monthly premium for the plan, and that premium covers medical services (doctor visits, hospital stays) and prescription drugs. The formulary is part of your plan documents, and you use Humana's pharmacy network to fill prescriptions.

If you have Original Medicare and a Humana Part D plan, you pay a separate monthly premium just for drug coverage. Part D plans have a different cost structure: you pay a deductible (if your plan has one), then copays or coinsurance for each prescription, and if your drug costs exceed a certain amount in a year, you enter the "coverage gap" where you pay a higher percentage of the cost until you reach the out-of-pocket maximum.

Medicare Advantage plans often have lower or no deductibles for drugs, but they may have higher copays for individual prescriptions. Part D plans often have higher deductibles but lower copays. The best choice depends on how many drugs you take and how expensive they are. Use Medicare.gov's Plan Finder to compare the total estimated cost of your medications under different Humana plans.

How to Request a Drug Exception or Appeal a Denial

If Humana denies coverage for a drug you need, your doctor can file a formulary exception request. Your doctor writes a letter to Humana explaining the medical reason why you need this specific drug — for example, you are allergic to the alternatives, or you have tried them and they did not work. Humana has 24 to 72 hours to respond to urgent requests and 7 days for standard requests.

If Humana denies the exception, you can file an appeal. Your doctor or you can submit a written appeal to Humana's appeals department, again explaining why you need the drug. Humana must respond within 30 days. If you disagree with the appeal decision, you can request an independent review through Medicare, which is free and separate from Humana.

To start an exception or appeal, call the customer service number on your Humana insurance card and ask to speak with the pharmacy department. They will tell you whether to submit the request by phone, fax, or mail, and they can answer questions about what information your doctor needs to include.

Frequently Asked Questions

Can I use any pharmacy with Humana's drug coverage?

No. Humana has a network of preferred pharmacies, and you pay less when you use them. Using an out-of-network pharmacy costs more. Your plan documents list the pharmacy network, or you can search for pharmacies on Humana's website. Mail-order pharmacies are usually available for maintenance drugs (medications you take regularly for chronic conditions).

What if I cannot afford my copay for a drug I need?

Ask your doctor or pharmacist about patient information programs run by the drug manufacturer. Many pharmaceutical companies offer free or reduced-cost drugs to people who meet income requirements. You can also ask Humana about switching to a generic version or a different drug on a lower tier. Some Humana plans offer copay information programs as well.

Do I have to use Humana's formulary, or can my doctor prescribe any drug?

Your doctor can prescribe any drug they believe is medically necessary. However, if the drug is not on Humana's formulary, you will either pay the full cost out of pocket or request an exception. Humana will not pay for non-formulary drugs unless an exception is approved.

When can I change to a different Humana plan if my drug is not covered?

You can change plans during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event, such as losing other health coverage or moving to a new state. Outside these windows, you are locked into your current plan for the year. If a drug you depend on is being removed mid-year, contact Humana to discuss your options.

How do I know if a generic version of my drug is on the formulary?

Search for both the brand name and the generic name in Humana's formulary. Generic versions are usually on a lower tier and cost less. Your doctor or pharmacist can tell you the generic name if you do not know it. If the generic is covered but the brand name is not, ask your doctor whether switching to the generic is safe for your condition.