Pharmacy Management Updates

Humana strives to make the prescription process as simple as possible for providers and members. Some prescriptions, however, require more attention than others.

The Humana Clinical Pharmacy Review (HCPR) team oversees step therapy and handles requests related to prior authorization and overriding dispensing limits. The team is centrally located in Louisville, Ky., and operates Monday-Friday, 8 a.m. to 9 p.m. EST.

Prior authorizations
Some drugs must undergo a criteria-based approval process prior to a coverage decision. If you need to obtain prior authorization for a prescription, you can use one of the following methods:

1) Submit your request online with the new Web tool. (See the box on this page for more information.)

2) Call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m. to 9 p.m. EST. When calling in a request, be prepared with the following information:

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

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

3) Fax the form to HCPR at (877) 486-2621. Fax forms can be downloaded online through the following process:

• Go to the "Provider" area of www.humana.com
• Under "Quick Links," choose "Prescription Tools"
• Scroll down to the "Prior Authorization" link

You can also view a list of drugs that require prior authorization by clicking on "Humana's Drug List" on the same page as the "Prior Authorization" link.

Maximum dispensing limits
Maximum dispensing limits are based on product information approved by the Federal Drug Administration (FDA) and recommendations from the drug's manufacturer. These limits are reviewed and approved by Humana's Pharmacy and Therapeutics Committee, which is composed of both pharmacists and physicians.

If a patient's medical condition warrants additional quantities, call HCPR at 1-800-555-CLIN (2546), Monday-Friday, 8 a.m.-9 p.m. EST. You should be prepared with the same information as for a prior authorization request (see list at left). For a list of drugs with a dispensing limit, take the following steps:

• Go to the "Provider" area of www.humana.com
• Under "Quick Links," choose "Prescription Tools"
• Choose "Humana's Drug List"
• Click on the link under "Quantity Limit" under "Updates"

Step therapy
The Medicare Prescription Drug Plan is subject to step therapy protocols. Step therapy protocols require patients 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.

Some drugs are restricted to a particular gender and/or age group for coverage. This is based on how the drug is to be used and the subpopulation the drug is intended to treat.

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

For information about Exception and Appeals take the following steps:

• Go to the "Provider" area of www.humana.com
• Under "Quick Links," choose "Prescription Tools"
• Scroll down to the "Exception and Appeals" link

Generally, HCPR will give providers a decision within 72 hours of receiving their supporting statement for authorization. Providers can request an expedited review if the standard response time would cause serious harm or endanger a member's health. HCPR will make the decision within 24 hours if the patient's medical condition requires it.

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