Humana Health insurance did not pay second guess doctor Fort Worth Texas

Did your doctor request allowance for the medication from Humana. Doctor can request but it is not always 100%.

Here's one possible problem, did the medication have FDA approval to treat infection? Most health insurers won't cover a medication for any use other than FDA approved treatments. For example, some doctors use a cancer pain medication for migranes. Works great however FDA has not approved it for that use. Rx plans won't cover it unless it is for the intended FDA approved use.

If the medication is approved that you took (for infection), is it then a non-formulary medication with Humana? Does your health plan have tier 3 level Rx benefits for non-formulary brand?

Best thing to do if it is FDA approved is to have your doctor contact Humana and request an exception for use of the medication. Often contracted physicians can get approvals for non-formulary meds for patients if they can demonstrate the medical necessity of the drug over other options.

BTW, you can file a grievance with your health insurer to reconsider and provide documention from your doctor with that. Those will be reviewed by real doctors at the health insurer.

Good luck on this but certainly you should appeal to the health insurer.

The medication is FDA approved for this type of infection (fungal). The problem is, the infection was on my thumb and the medication is used for infections of the foot. They denied it because of the location of the infection. My doctor called them and they still would not pay. The drug is on their prefered list also.

Write in for a grieveance. Address is: Humana Health Plans. PO BOX 14546 Lexington, KY 40512-4546. I imagine that the denial was from the fact that the medication being used is actually for a different area of the body, but I'd have to look at the claim to be sure. The denial is stemming from the fact (most likely) that Humana thinks your doctor is misbilling or perhaps even trying to pull a fast one on them. Not saying that he is, but I can see this from Humana's perspective, too. Good luck.

Claims people ARE actually medically trained. I'm glad it worked for you, but even if a medication is FDA approved, it may not be universally used for other types of conditions. (Using it for purposes other than intended and all that.) I'm not trying to take sides, but Humana was right to deny that claim and that information is expressly written in your certificate.