Pharmacy Team Helps with Prescriptions

Humana strives to make the prescription process as uncomplicated as possible for both providers and members. In order to help members with prescriptions that require special attention, Humana has a dedicated team available to help.

The Humana Clinical Pharmacy Review (HCPR) team performs clinical reviews of all medications that require prior authorization, step therapy or medications that request overrides of maximum dispensing limits. The team consists mostly of front-line call takers and other team members who process faxed requests for authorization from providers. HCPR is centrally located in Louisville, Ky., and operates Monday-Friday, 8 a.m. to 9 p.m. EST. HCPR has recently opened a satellite call center in Phoenix that will help support the Midwest and Western regions of the United States.

Prior authorizations
Some drugs must undergo a criteria-based approval process prior to a coverage decision. If you need to obtain a prior authorization for a prescription, you can either phone or fax the request to HCPR. To phone in a request, call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m. to 9 p.m. EST. When phoning an authorization request, be prepared with the following information:

• Patient demographic information
• Drug being requested
• Patient diagnosis
• Drug allergies or medical conditions
• Other therapies or procedures attempted
• Desired length of therapy

Most requests for authorization require the appropriate lab information before they can be processed.

You can also fax the authorization request to (877) 486-2621. For copies of the fax forms, call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m. to 9 p.m. EST. You can also download the forms online. Go to www.humana.com and then select “Providers.” Then choose “Provider Resource Center,” “Prescription Tools and Resources,” and finally “Prior Authorization Forms.” You can view a list of drugs that require prior authorization on the same Web page.

Maximum dispensing limits
Humana has implemented a number of maximum dispensing limits on certain medications on which there are safety concerns, or as a means to maximizing dosing options. The maximum dispensing limits are based on Federal Drug Administration (FDA) approved product information and drug manufacturer’s recommended dosing guidelines. Dispensing limits are reviewed and approved by Humana’s Pharmacy and Therapeutics Committee, which is composed of both pharmacists and physicians. Humana believes this program will help members with obtaining the appropriate and optimal dose required for treating their condition.

If a patient’s medical condition warrants additional quantities, call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m. to 9 p.m. EST. You should be prepared with the same information that is needed for a prior authorization request. For a list of drugs with a dispensing limit, go to www.humana.com and choose “Providers” and then “Provider Resource Center.” Then select “Prescription Tools and Resources,” choose “Drug Lists and Forms,” and click on the link “About Dispensing Limits.”

Step therapy
The Medicare Prescription Drug Plan is subject to step therapy protocols as a component of Humana’s standard Drug Utilization Review (DUR) program. Step therapy protocols require patients to try a particular drug (or drugs) before receiving another drug. In other words, patients are required to utilize medications commonly considered first-line before using medications considered second-line or third-line. These protocols are used to promote established national treatment guidelines. Additionally, step therapy protocols assist in promoting safe and cost-effective medication therapy.

An example of a step therapy protocol is Humana’s COX II step therapy program. Before a member can receive a COX II, they are required to try at least two nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) or have a condition that places them at risk for complications or bleeding (i.e., advanced age, history of gastrointestinal bleeding, taking a prescription PPI or H2RA, anti-platelet therapy, oral corticosteroid, bisphosphonate, warfarin, anti-neoplastic and/or LMWH).

If you have questions about a step therapy regimen, please call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m. to 9 p.m. EST.

Exception and denial of requests
For an exception to a Medicare Part D drug management tool, providers should call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m. to 9 p.m. EST.

Exception and Appeals information, including forms, can be found on Humana’s Web site at: http://apps.humana.com/prescription_benefits_and_services/execreq.asp?
processcode=4008&srcsite=home&srcmbr=medicare.

Generally, HCPR will give providers a decision no later than 72 hours after receiving the physician’s supporting statement for authorization. In situations where there is substantial reason to believe that a request processed within the standard time frame would cause serious harm or endanger a member’s life and/or health, providers can request an expedited review, and HCPR will make the decision within 24 hours — or sooner if the patient’s medical condition requires it.

All approved authorization requests — including requests for a formulary exception, a drug placement exception or a utilization management exception (e.g., dosage or quantity limits or step therapy requirements) — are faxed directly to the provider in a summary format that states the name of the approved drug and the length of the approval. Denied requests are also faxed to the provider with an explanation of the reason for denial. HCPR concurrently notifies patients of their decision via mail. If HCPR does not approve the request, it will explain the reason for the denial and inform the member of his or her right to appeal HCPR’s decision.

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