Pharmacy, prescription, and medication benefits and information.

Humana works with you and your doctor to make sure you get the medications you need. The Drug Guide includes the drugs covered by the Humana Gold Plus Integrated, A Commonwealth Coordinated Care Plan (Medicare-Medicaid Plan).

You will sometimes have to pay for your prescriptions. There are also limits to your drug benefits.

What is the plan's Prior Authorization and Step Therapy Criteria?

Read more about them here:

Best Available Evidence (BAE) policy

These are rules that specify the requirements of Part D plans in the administration of the low-income subsidy program, including the lowering of costs for subsidy-eligible individuals. In certain cases, CMS systems do not always reflect a beneficiary’s correct low-income subsidy (LIS) status, also known as ‘extra help’. As a result, the right subsidy information has not been shared with the Part D plan. To help with the situation, CMS created the Best Available Evidence (BAE) policy. This policy requires sponsors (health plans) to correct the cost-sharing for low-income beneficiaries when presented with proof that your information is not right.

Best Available Evidence (BAE) (link opens in new window) 

Quality Assurance Policy and Procedures

Humana wants its members to get safe, high-quality and affordable medication. Several policies and procedures make sure this happens.

The Concurrent (65 Kb) & Retrospective Drug Utilization Review (DUR) program (67 Kb) programs were created to improve health outcomes. DUR does this by making sure prescriptions are appropriate, medically necessary, and unlikely to have bad medical results.

Pharmacy Claim Form

Prescription Drug Claim Form for Member Reimbursement

Claim Form (904 Kb)