Humana's Your Practice

Pharmacy Management Guidelines Available

In a perfect prescription scenario, a provider writes a script, the patient submits the script at a pharmacy and the pharmacy processes the script with no problems.

In the real world, however, some medications require additional intervention, such as medical necessity review for noncovered medications.

The following pharmacy management procedures pertain to medications that may require intervention and detailed lab information.

Clinical Pharmacy Review
Humana’s Clinical Pharmacy Review area oversees the review of exceptions to noncovered medications, dispensing limits and authorization for continued therapy.

When a physician or office staff member contacts Humana for a medical exception, the following patient information must be provided, according to Debbie Meyer, clinical pharmacist and process manager for Humana’s Clinical Pharmacy Review.

Patient demographic information
The drug being requested
Any drug allergies or medical conditions
The patient diagnosis
Other therapies or procedures attempted
The desired length of therapy
Most requests require the appropriate lab information before they can be processed

“Providers can call or fax medical exception requests for any drug to Humana’s Clinical Pharmacy Review area,” said Meyer. “A telephone call with the appropriate information for medical exception review may receive immediate approval. If the caller cannot or does not have all of the necessary medical information for review, a general fax form is sent for the physician to complete and return.”

Providers can also get medical exception review information online at www.humana.com. To access the site, go to the “Provider” area on www.humana.com, select “Prescription Tools and Resources,” and choose “Drug List Search.” Then select “Print a Humana Drug List.” On this page, scroll down to “Prior Authorization and Dispensing Limits” to find current information.

All written physician requests will receive a response within 48 normal business hours. For more information, physicians can call Humana’s Clinical Hotline at (800) 555-2546 on Monday through Friday from 8 a.m. to 6:30 p.m. EST. Fax requests can be submitted anytime to (877) 486-2621.

Denial of exception requests
and the appeals process
All requests-for-exception approvals are sent directly to the physician via a fax summary that states the name of the drug approved and the length of approval, according to Meyer. All denials are sent to the patient, as well as to the physician.

“The appeals process and all required information is explained and supported in the content of the denial letter,” Meyer said. “All contact information for individual appeals rights is listed in detail in the denial letter to the patient.”

Maximum dispensing limits
A dispensing limit is a method used to encourage the appropriate use of drugs, according to Betsy Warren, Pharm.D., clinical pharmacist for Humana’s Innovation Center.

“It involves placing quantity, age or other restrictions into our pharmacy claims system to allow opportunities for clinical intervention when necessary and to encourage safety and reasonableness in dispensing,” Warren said.

Dispensing limits are reviewed and approved by the Pharmacy and Therapeutics Committee, Warren added. The quantities and restrictions are based on Federal Drug Administration (FDA) approved product information and other sources of medical literature.

For more information about Humana’s pharmacy management procedures, call your market medical director.