800-555-2546

308203ALL0923‐A GCA080XHH. Prescriber quick reference guide. CenterWell Pharmacy/CenterWell Specialty Pharmacy. CenterWell Pharmacy®(mail‐delivery pharmacy for maintenance medications and durable medical equipment) 800‐379‐0092 (Fax: 800‐379‐7617), Monday – Friday, 8 a.m. – 11 p.m., and Saturday, 8 a.m. – 6:30 p.m., Eastern time.

800-555-2546. 800-555-2546 (TTY: 711) between 8 a.m. – 8 p.m. Eastern time, Monday – Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m. - 8 p.m., Monday-Friday. How do I find a Network Pharmacy

•Call HCPR at 800-555-CLIN (800-555-2546) Requirements for prior authorization fax form •National Provider Identifier(NPI) •Address ofmember •Address of prescriber •Time period and outcome of past therapy tried/failed NOTE: Include medical records ONLY for medical necessity or off-label-use review (not for everysubmission) Questions 800-555-CLIN (800 …

Humana Clinical Pharmacy Review Fax 1-877-486-2621 (HUMANA-I) Telephone 1-800-555-2546 (CLIN) INFORMATION REQUIRED TO PROCESS DRUG AUTHORIZATIONSPhone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.The side effects of taking 800 milligrams of ibuprofen include upset stomach, bloating, gas and mild heartburn, according to Drugs.com. Other possible side effects include itching ...800-555-2546 to ask for an exception. We will reply within 24 hours after we get your doctor ’s request. Drugs listed in the covered alternatives category are covered and are the most affordable options. DRUG CATEGORY NON-PDL (NOT COVERED) COVERED ALTERNATIVES Asthma/COPDYou can start a prior authorization request or ask your doctor to contact Humana Clinical Pharmacy Review (HCPR) for approval. Here are the ways your doctor can request …Plan/Medical Group Phone#: 1-800-555-2546 Plan/Medical Group Fax#: 1-877-486-2621. Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request. How did the patient receive ...Fax: 1 (800) 555-2546; Phone: 1 (877) 486-2621; Humana Universal Prior Authorization Create; By Us. Arcadia; California; Illinois; Louisiana; Medicare Coverage (all States) Missippi; Oklahama; Texas; How to Write. Stepping 1 – Enter the patient’s whole print, ihr member number, their group number, their complete address.With pdfFiller, an all-in-one online tool for professional document management, it's easy to fill out documents. Over 25 million fillable forms are available on our website, and you can find the 1-800-555-2546 fax to 1-877-486-2621 in a matter of seconds. Open it right away and start making it your own with help from advanced editing tools.

Fax: 1 (800) 555-2546; Phone: 1 (877) 486-2621; Humana Universal Prev Approval Form; By State. Arkansas; California; Colorado; Louisiana; Medicare Coverage (all States) Mississippi; Oklahama; Texas; How until Write. Single 1 – Enter and patient’s full name, their member item, their group number, the complete address.Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.With pdfFiller, an all-in-one online tool for professional document management, it's easy to fill out documents. Over 25 million fillable forms are available on our website, and you can find the 1-800-555-2546 fax to 1-877-486-2621 in a matter of seconds. Open it right away and start making it your own with help from advanced editing tools.Having a Roku device is a great way to access all your favorite streaming services in one place. But sometimes, you may run into technical issues that require assistance from custo...PRIOR AUTHORIZATION REQUEST FORM EOC ID Administrative Product - Universalr r rPhone 800-555-2546 Fax back to 1-877-486-2621 HUMANA INC manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the number listed above.

800-585-7417 (TTY: 711) Monday – Friday, 7 a.m. – 8 p.m., Central time Humana is a stand-alone prescription drug plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal. Call 800-585-7417 (TTY: 711) for more information. All product names, logos, brands and trademarks are property of their respectiveGenerally, Humana will only approve a request if a covered medicine wouldn't work as well OR would have a negative effect on your health. To ask for an approval, your health care provider can contact HCPR (Humana Clinical Pharmacy Review) at 1-800-555-2546, Mon-Fri 8am-8pm EST. Rx Tiers & Cost1‐800‐555‐2546. Improving or maintaining physical health: Patients report whether their physical health is the same as or better than expected in the past two years. • Applaud your patients’ physical health when possible, and encourage them to stay positive. If you have a Humana plan, your prescriber can call the Humana Clinical Pharmacy Review at 800-555-2546, Monday – Friday, 8 a.m. – 8 p.m., Eastern time. If you choose to pay for a drug out of pocket, there are still ways to save. Changes to Humana’s drug formulary. Humana’s Medicare formulary updates each year. F: 855-865-9469 F: 866-533-5493 F: 800-823-5520 Molina Humana of SC P: 855-237-6178 P: 800-555-2546 F: 855-571-3011 F: 877-486-2621 Date of Request for Authorization Patient/Member Name First Middle Last DOB City/State/Zip Medicaid Number MCO ID Number Address (Street, Apt.#) Phone•Call HCPR at 800-555-CLIN (2546). Requirements for prior authorization fax form •National Provider Identifier(NPI) •Address ofmember •Address of prescriber •Time period and outcome of past therapy tried/failed NOTE: Include medical records ONLY for medical necessity or off-label-use review (not for everysubmission)

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Humana Clinical Pharmacy Review (HCPR) 1-877-486-2621 P.O. Box 14601 Lexington, KY 40512. You may also ask us for a coverage determination by phone at 1-800-555-2546 …Finding a place to live that fits within your budget can be a challenge, especially in today’s housing market. However, there are still options available that offer affordable livi...Phone requests: Call 1-800-555-CLIN (2546), Monday – Friday, 8 a.m. – 8 p.m., local time. Phone user guide. Fax requests: Complete the applicable form and fax it to 1-877-486-2621.Coverage Determination (Prior Authorization) Phone: 1-800-555-2546. Coverage Determination (Prior Authorization) Fax: 1-877-486-2621. Redetermination (First Level Appeal) Form. Redetermination Appeal Phone: 1-877-320-1235. Redetermination Appeal Fax: 1-866-556-2128. Expedited Redetermination Appeal Phone: 1-800-867-6601

Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 75906ALL0922-D Humana manages the pharmacy drug benefit for your patient named below. Certain requests for coverage require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegiblePlan/medical group phone number: 1-800-555-2546 . Plan/medical group fax number: 1-877-486-2621 Urgent 1 Nonurgent Requested drug name: Patient information Prescribing provider information Patient name: Prescriber name: Member number: Prescriber fax number: Policy/group number: Prescriber phone:Prior authorization for pharmacy drugs: 800-555-2546. Medicaid case management: 877-856-5707. Availity customer service/tech support/medical and behavioral health prior …Fax: 1 (800) 555-2546; Telephones: 1 (877) 486-2621; Humana Universal Preceding Authorisation Form; By Set. Arcadia; California; Colorado; Lousiana; Medicare Coverage (all States) Missingissippi; Oklahama; Texas; How till Write. Step 1 – Entered the patient’s full name, to member amount, hers group item, their finished address. Humana Clinical Pharmacy Review 1 -800 -555 -2546 1 -866 -930 -0019 Medications Administered in Provider Office 1 -866 -461 -7273 1 -888 -447 -3430 PASSPORT HEALTH PLAN BY MOLINA DEPARTMENT PHONE FAX/OTHER Medical, Behavioral Health, Substance Use, Inpatient & Outpatient 1-800-578-0775 1-833-454-0641 www.Availity.com • Calling Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546). Humana will make a decision based on your health needs within 24 hours after the request from your doctor. Some drugs may have extra limits. This can include: • Prior authorization (PA): Your doctor must get approval from Humana before these drugs are … Phone: 800-555-2546 Fax: 877-486-2621 420403OK0224 OKHM9G4EN Humana manages the pharmacy drug benefit for your patient listed below. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Find who called from. (800) 555. Enter the final 4 digits to get the owner's name. Search. 1-800-555-XXXX is a prefix hosted by the carrier . It includes 60 phone numbers. The city is within County. This number is from the Zip Code. Jun 9, 2021 · Who called you from 8005552546 ? +1 800-555-2546 NEUTRAL COMPANY toll free. Phone number 8005552546 has neutral rating. 9 users rated it as positive and 7 users as negative. This phone number is mostly categorized as Company (6 times), Telemarketer (5 times) and Call centre (2 times). This ratings are based on reports of visitors of this web ... Phone requests: Call 1-800-555-CLIN (2546), Monday Friday, 8 a.m. 8 p.m., local time. What is a prior authorization form for medication? A prior authorization (PA), sometimes referred to as a pre-authorization, is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific … Fill 800 555 2546, Edit online. Sign, fax and printable from PC, iPad, tablet or mobile with pdfFiller Instantly. Try Now! Who is calling or texting from 800-555-2546 phone number? Reverse Phone Lookup registered owner's full name, address, public records & background check for +1 800-555-2546 with Whitepages.

Department Contact Phone Number: 1-800-555-2546 (CLIN) This company offers the consumers a wide scope of products and programs to be able to accommodate a variety of people. They offer a variety of plans, individual insurance products, a Vitality rewards program, Military benefits, Dental and Vision, Life and Supplemental Insurance, Right ...

Then, have your provider call CenterWell Clinical Pharmacy Review at 800-555-CLIN (800-555-2546), Monday – Friday, 8 a.m. – 8 p.m. or submit a prior …Business Details. Location of This Business. 652 N Sam Houston Pkwy E Ste 300, Houston, TX 77060-5912. Headquarters. 3170 Fairview Park Dr, Falls Church, VA 22042-4516. BBB File Opened: 1/1/1962 ...On May 1, all patients with new prescriptions must have a prior authorization for Nuedexta for the claim to be covered. Prescribers with questions regarding this change may call the Humana Clinical Pharmacy Review team at 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m., Eastern time. Starting May 1, 2018, Humana will ... Todos los proveedores de Medicaid deberían contactar al estado correspondiente para cualquier consulta y servicios relacionados con Medicaid. Florida Medicaid: 800-477-6931. Illinois Medicaid: 800-787-3311. Kentucky Medicaid: 800-444-9137. Louisiana Medicaid: 800-448-3810. Ohio Medicaid: 877-856-5707. Fill 800 555 2546, Edit online. Sign, fax and printable from PC, iPad, tablet or mobile with pdfFiller Instantly. Try Now! Looking for a suitable rental property can be a daunting task, especially when you are on a tight budget. However, with the right approach and resources, finding houses for rent un...(HCPR) at (800) 555-2546 (TTY: 711) between 8 a.m. - 8 p.m. Eastern time, Monday – Friday. For a member in Puerto Rico, your healthcare provider can contact HCPR in Puerto Rico at (866) 4885991 between 8 a.m.- - 8 p.m. local time, Monday – Friday. How long does the exception process take?

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1-800-555-2546, Monday - Friday, 8 a.m. - 8 p.m., local time. Humana” is the brand name for plans, products, and services provided by one or more of the subsidiaries and affiliate companies of Humana Inc. (“Humana Entities”). Plans, products, and services are solely and only provided by the one or more Humana Entities specified on the plan, product, or … Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process. The 800 mark on silver refers to the purity of the metal. Pure silver has a 1,000 grade value. Silver with an 800 grade value is a silver alloy containing 800 parts silver and 200 ... authorization status, call 1-800-865-8715, choose option 2. For other claims-processing questions, choose option 3. Humana Medicare Customer Care 1-800-281-6918 (TTY: 711) 8 a.m. – 8 p.m., seven days a week 7 a.m. – 7 p.m., Monday – Friday Puerto Rico: 1-800-256-3316 Humana Clinical Pharmacy Review (HCPR) 1-800-555-CLIN (1-800-555-2546) Plan/Medical Group Phone#: 1-800-555-2546 Plan/Medical Group Fax#: 1-877-486-2621. Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request. How did the patient receive ...1‐800‐555‐2546. Improving or maintaining physical health: Patients report whether their physical health is the same as or better than expected in the past two years. • Applaud your patients’ physical health when possible, and encourage them to stay positive.Prior authorization for pharmacy drugs: 800-555-2546. Medicaid case management: 877-856-5707. Availity customer service/tech support/medical and behavioral health prior authorization submission support: 800-282-4548. Fraud, waste, and abuse. Special Investigations Unit (SIU) hotline: 800-614-4126 (24/7 access)Having a Roku device is a great way to access all your favorite streaming services in one place. But sometimes, you may run into technical issues that require assistance from custo... Humana Clinical Pharmacy Review Fax 1-877-486-2621 (HUMANA-I) Telephone 1-800-555-2546 (CLIN) INFORMATION REQUIRED TO PROCESS DRUG AUTHORIZATIONS additional cost, your health care provider can contact Humana Clinical Pharmacy Review (HCPR) at 800-555-2546 (TTY: 711) between 8 a.m. – 8 p.m. Eastern time, Monday – Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m. - 8 p.m. local time, Monday-Friday.Humana-universal-prior-authorization-form.pdf - PRIOR AUTHORIZATION REQUEST FORM EOC ID: Admin - State Specific Authorization Form 43 Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 Humana …Consumer Cellular is a popular mobile phone carrier in the United States that offers affordable plans and excellent customer service. One of the ways customers can reach out to the... ….

Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.1-800-555-2546, Monday - Friday, 8 a.m. - 8 p.m., local time. Humana” is the brand name for plans, products, and services provided by one or more of the subsidiaries and affiliate companies of Humana Inc. (“Humana Entities”). Plans, products, and services are solely and only provided by the one or more Humana Entities specified on the plan, product, or …Phone: 800-555-CLIN (800-555-2546) Hours of operation: Monday – Friday, 8 a.m. - 8 p.m., Eastern timePRIOR AUTHORIZATION REQUEST FORM Phone: 1-800-555-2546 ... Start a Request. Scroll To Learn More. Why CoverMyMeds Improving efficiencies without sacrificing the essentials 70% 1 of users reported time savings; 35% 2 faster determinations than phone or fax; HIPAA compliant and available for all plans and all medications; No cost to providers …Prescribers with questions regarding this change may call the Humana Clinical Pharmacy Review team at 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m., Eastern time. In Puerto Rico, call 1-866-488-5991, Monday through Friday, 8 a.m. to 8 …Department Contact Phone Number: 1-800-555-2546 (CLIN) This company offers the consumers a wide scope of products and programs to be able to accommodate a variety of people. They offer a variety of plans, individual insurance products, a Vitality rewards program, Military benefits, Dental and Vision, Life and Supplemental Insurance, Right ...Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process. 800-555-2546, Pharmacy Review (HCPR). To contact HCPR, please call 1-800-555-2546 or fax your prior authorization request to 1-877-486-2621. If your Humana-insured patient will be using RightSourceRx, please be sure to write the prescription for up to a three-month supply and indicate the number of refills., Brand-name Spiriva with HandiHaler will continue to be covered and can be filled for your patients. Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in Puerto Rico should call 866-488-5991., Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 75906ALL0922-D Humana manages the pharmacy drug benefit for your patient named below. Certain requests for coverage require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible, 610649 3191504 318293. Company PBM BIN PCN Group Override Process Leave Blank 866-610-2773 004336 ADV RX0860 Caremark PBM Helpdesk Clinical PA Number MCAIDADV WFSA, Whitepages.com provides a reverse phone number lookup feature for 800 numbers in addition to most other landline numbers. Other websites, such as WhoCallsMe.com, provide listings o..., Brand-name Spiriva with HandiHaler will continue to be covered and can be filled for your patients. Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in Puerto Rico should call 866-488-5991., 610649 3191504 318293. Company PBM BIN PCN Group Override Process Leave Blank 866-610-2773 004336 ADV RX0860 Caremark PBM Helpdesk Clinical PA Number MCAIDADV WFSA, Phone requests: Call 1-800-555-CLIN (2546), Monday – Friday, 8 a.m. – 8 p.m., local time. Fax requests: Complete the applicable form and fax it to 1-877-486-2621. What is the fax number for Humana Medicare PA? Submit your own prior authorization request. Download, fill out and fax one of the following forms to 877-486-2621: Request for ..., Member/Provider Services contact center. 855-223-9868 (TTY: 711) Monday through Friday, 8 a.m. to 5 p.m., Central time. Member 24-hour nurse advice line (available 365 days a year) 800-854-6619. Provider Relations. [email protected]. Humana Healthy Horizons in Oklahoma is a Medicaid product of Humana Wisconsin Health ..., 1-800-555-CLIN (1-800-555-2546); Monday – Friday, 8 a.m. to midnight EST Medicare: 1-800-457-4708. Other Humana Contact Information. Humana Clinical Pharmacy Review 1-800-555-CLIN (1-800-555-2546) (Fax: 1-877-486-2621); Monday – Friday, 8 a.m. to 12 midnight EST., The 800 mark on silver refers to the purity of the metal. Pure silver has a 1,000 grade value. Silver with an 800 grade value is a silver alloy containing 800 parts silver and 200 ..., To learn more, call Availity at 1-800-282-4548 or visit Availity.com. Availity provides the following functions: ... 1-800-555-2546 Fax: 1-877-486-2621 to 11 p.m. Humana Pharmacy (mail order for maintenance medications) 1-800-379-0092 Fax: 8 a.m. 1-800-379-7617 Monday through Friday, ..., You may also ask us for a coverage determination by phone at 1-800-555-2546 or through our website at . ... Llame al <1-800-787-3311>. La llamada es gratuita. , Prior authorization for pharmacy drugs: 800-555-2546. Medicaid case management: 877-856-5707. Availity customer service/tech support/medical and behavioral health prior authorization submission support: 800-282-4548. Fraud, waste, and abuse. Special Investigations Unit (SIU) hotline: 800-614-4126 (24/7 access), May 3, 2022 by tamble. Humana Medical Claim Appeal Form – Medicare and Medicaid programs demand the use of health care declare types. Your burden will be based on the form you utilize. Make use of the UB-04, that has much more job areas, or perhaps the CMS-1500. The Component-A companies take advantage of the CMS-1500 type., “Digits” are the symbols or characters used to represent a number visually. A number like five contains one digit, whereas a number like 555 contains three digits. This is easily s..., The Humana Clinical Pharmacy Review (HCPR) interactive voice response (IVR) system, accessed by dialing 1-800-555-2546 , is designed to offer an alternative method for our provider partners to submit new requests for pharmacy authorization, check on the status of existing authorizations, and determine if an authorization is , Plan/medical group phone number: 1-800-555-2546 Plan/medical group fax number: 1-877-486-2621. For use in clinical trial? (If yes, provide trial name and registration number): 1. A request for prior authorization that if determined in the time allowed for nonurgent requests could seriously jeopardize the life or health of the covered person or ..., Last updated Feb 2024. Registered to: Phone Ownersname. In their ––. View Owner's Name. Leaflet | Protomaps © OpenStreetMap. Area Code & Provider Details. Phone …, 30 Jun 2023 ... P: 855-237-6178 P: 800-555-2546. F: 855-571-3011 F: 877-486-2621. Date of Request for Authorization. Patient/Member Name. First. Middle. Last., •Call HCPR at 800-555-CLIN (2546). Requirements for prior authorization fax form •National Provider Identifier(NPI) •Address ofmember •Address of prescriber •Time period and outcome of past therapy tried/failed NOTE: Include medical records ONLY for medical necessity or off-label-use review (not for everysubmission) Questions Call 800-555-CLIN …, 1-800-555-2546, Monday - Friday, 8 a.m. - 8 p.m., local time. Humana” is the brand name for plans, products, and services provided by one or more of the subsidiaries and affiliate companies of Humana Inc. (“Humana Entities”). Plans, products, and services are solely and only provided by the one or, By calling 800-555-2546, Monday – Friday, 8 a.m. – 6 p.m., Eastern time; When applicable, please use one of the below forms when submitting an authorization request for medication or Synagis ®. Prior Authorization …, 1‐800‐555‐2546. Improving or maintaining physical health: Patients report whether their physical health is the same as or better than expected in the past two years. • Applaud your patients’ physical health when possible, and encourage them to stay positive., 800-555-2546 Fax: 877-486-2621 Monday through Friday, 8 a.m. to 6 p.m. Medication intake team—Prior authorization for medication administered in medical office. , , Plan/medical group phone number: 1-800-555-2546 Plan/medical group fax number: 1-877-486-2621. For use in clinical trial? (If yes, provide trial name and registration number): 1. A request for prior authorization that if determined in the time allowed for nonurgent requests could seriously jeopardize the life or health of the covered person or ..., Jan 1, 2020 · Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process. , Phone: 800-555-2546 Fax: 877-486-2621 420403OK0224 OKHM9G4EN Humana manages the pharmacy drug benefit for your patient listed below. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above., Humana Clinical Pharmacy Review Fax 1-877-486-2621 (HUMANA-I) Telephone 1-800-555-2546 (CLIN) INFORMATION REQUIRED TO PROCESS DRUG AUTHORIZATIONS, Created Date: 10/30/2017 3:09:58 AM, Phone requests: Call 1-800-555-CLIN (2546), Monday – Friday, 8 a.m. – 8 p.m., local time. Phone user guide, PDF. Fax requests: Complete the applicable form and fax it to 1-877 …, Jan 1, 2020 · Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.