HealthRX.com · Printable appeal checklist
Humana Mounjaro prior authorization and appeal packet
Use this to assemble a Mounjaro coverage request or appeal with your prescriber's office: your plan type and case numbers, the documents to attach, a record of every call and letter, and the federal deadlines for Medicare drug plans and for employer or individual plans. Check each deadline against the letter you received.
Plan and request details
Plan typeMedicare Advantage or Part D / employer / individual
Plan name and member ID
Prescriber name, phone and fax
Diagnosis and ICD-10 code from the prescriber
Date the request was sent
Date on the denial notice, and the reason it gives
Case or reference number
Documents to attach
Answer the reason in the denial letter directly. A missing document is the easiest denial to reverse.
- Prescriber note confirming the type 2 diabetes diagnosis
- Most recent HbA1c result and the date it was drawn
- Metformin history: dates, doses, and why it stopped or cannot be used
- Other diabetes medicines tried, with dates and results
- Kidney function result, if it limits which medicines can be used
- Pharmacy fill history for earlier diabetes prescriptions
- Prescriber's supporting statement or letter of medical necessity
- Copy of the denial letter and the coverage rule it cites
Calls and letters
For every call, note the day, time, name and title of the person, and what was said. Keep originals and send copies.
| Date and time | Who (name and title) | What was said or sent | Reference number | Next step and deadline |
|---|---|---|---|---|
Medicare drug coverage deadlines (Humana Medicare Advantage and Part D)
- Coverage determination or exception: the plan decides within 72 hours, or 24 hours if expedited, once it has the prescriber's supporting statement.[1]
- Level 1 redetermination: ask within 65 days of the denial notice; the plan decides within 7 days, or 72 hours for a fast appeal.[2]
- Level 2 is the Part D Independent Review Entity, currently C2C Innovative Solutions.[3]
- Level 3 OMHA hearing: ask within 60 days of the IRE decision; in 2026 at least $200 must remain in controversy.[4]
Employer and individual plan deadlines (federal rules summarised by HealthCare.gov)
- File the internal appeal within 180 days (6 months) of the denial notice.[5]
- An internal appeal for a treatment you have not received yet must be decided within 30 days.[5]
- If the denial stands, ask in writing for external review within 4 months; standard reviews are decided within 45 days, expedited ones within 72 hours, and the insurer must accept the result.[6]
- In an urgent situation you can ask for external review at the same time as the internal appeal.[5]
Questions for Humana or the prescriber's office
- Is Mounjaro on my plan's formulary this year, and on which tier?
- Which prior authorization criteria does my plan apply, and can I have them in writing?
- Is there a step therapy rule, and do my past prescriptions already meet it?
- Was the denial for a missing document or for not meeting a criterion?
- Can this be handled as an expedited (fast) request?
- If approved, when does the approval end and need renewing?
- Which pharmacy gives the lowest cost under my plan?
Outcome
Decision and date
Approval end date or renewal date
Next appeal level and its deadline
Sources for the facts on this sheet
- Centers for Medicare & Medicaid Services. Exceptions (Medicare Prescription Drug Appeals & Grievances). Accessed 2026-10-17. https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions
- Medicare.gov, Centers for Medicare & Medicaid Services. Appeals in a Medicare drug plan. Accessed 2026-10-17. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans
- Centers for Medicare & Medicaid Services. Reconsideration by the Part D Independent Review Entity. Accessed 2026-10-17. https://www.cms.gov/medicare/appeals-grievances/prescription-drug/reconsiderations
- Centers for Medicare & Medicaid Services. Decision by the Office of Medicare Hearings and Appeals (OMHA). Accessed 2026-10-17. https://www.cms.gov/medicare/appeals-grievances/prescription-drug/office-of-medicare-hearings-and-appeals
- HealthCare.gov, Centers for Medicare & Medicaid Services. Internal appeals. Accessed 2026-10-17. https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
- HealthCare.gov, Centers for Medicare & Medicaid Services. External Review. Accessed 2026-10-17. https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.