Humana FAQ

Humana FAQ

Maine-Endwell Central School District – Humana FAQ

Q: Can members access providers in an area outside Humana’s service area?
Yes, as Humana is a passive PPO network. The same benefits are in place regardless of what provider is seen, as long as the provider accepts Medicare and sends the bill to Humana. Should a provider not send the bill to Humana, the retiree can forward it to Humana.

Q: What should I do if a providers states they do not accept Humana?
With the plan being passive this is often more of an educational opportunity for that provider. Humana will reach out to that provider so they understand that this is an Employer Group plan with benefits that pay the same for In/Out-of-Network providers. Once the providers understand that piece, they typically decide to bill Humana for member services. Humana has a very high success rate with Out-of-Network providers agreeing to see Group Medicare members.

Q: If a provider accepts Medicare but does not accept Humana, can that provider balance bill?
No, if the provider accepts Medicare they cannot balance bill members since Humana is a Medicare Advantage and reimburses at Medicare levels.

Q: Are referrals required?
No referrals are required.

Q: What diabetic supply companies are approved?
Humana utilizes AccuCheck and Trividia.

Q: When a member moves to Humana do they continue to pay Part B premium?  
Yes. They must continue to pay their Part B.

Q: Does Prior Auth and Step Therapy apply on prescriptions?
Prior Auth and Step Therapy are required however Humana will offer a 30 day grace period for any currently utilized prescriptions during the transition. During educational meeting or as a result of a member calling into Humana, if they inform Humana that they are currently on a drug that required prior auth or step therapy, we will ask them to inform their physician to contact Humana for such authorization. If they have it filled within the first 90 days after January 1, Humana will go ahead and cover the medication for 30 days, send a letter to both the retiree and the physician with instructions of what to do next in order for it to be covered in the future.

Q: Must members receive new scripts?
For Mail order, yes they will. Not for retail.
Q: How does the Worldwide coverage work?
Coverage when out of the US and US territories is limited to emergency services only.  Members would be responsible for paying at the point of service and then later submitting claims to Humana for reimbursement.  This coverage is limited to what Medicare would cover while in the US.  This benefit is included in the member’s Evidence of Coverage (EOC).

Q: Who do I contact if I have a provider or claim question?
Please contact ENV Call Center at 315-641-6353 or Toll Free at 1-800-887-9146. They may also be reach via email at: [email protected]
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